Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for and observation services you received on 
December 31, 2019-January 1, 2020. 
 
You asked the Plan to waive the copayment for the observation services.. You say that you have never paid 
medical bills because you have health insurance. The Plan denied your request. The Plan says you were 
charged this copayment 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 $200 
copayment for observation services.  
 
Records show that you went to the hospital on December 31, 2019 and were placed in observation at the 
hospital until you were discharged the following day. You have been asked to pay a $200 copayment for these 
observation 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 and observation services you 
received on December 31, 2019-January 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from May 13, 2019 to October 
23, 2019. 
 
You asked the Plan to pay for the chiropractic services. 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 
chiropractic services. 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 chiropractic services provided from May 13, 2019 to October 
23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are only supplied with the minimum 
necessary information needed to perform the tests ordered by the physician. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because this provider is out-of-network with the 
Plan, the ordering provider is out-of-network with the Plan, and 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 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 January 22, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple nosebleed treatment provided on April 1, 2020 
billed with CPT code 30901. 
 
You asked the Plan to pay for the nosebleed treatment. You say that this should not be denied as duplicate as 
this enrollee was seen twice on this date and received nosebleed treatment on both occasions. The Plan denied 
your request. The Plan says this was denied due to a Column 1/Column 2 coding edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to 
corroborate the medical record to support that criteria are met for billed services.  
 
Based on review of the file, we find that payment has been made for codes 99283 and 30903 to the provider at 
issue. The medical records submitted only document a single ER encounter for nosebleed on April 1, 2020. 
There is no evidence that the provider provided a second treatment for nosebleed on this date of service based 
on the records provided. Therefore, we decided that the Plan does not have to pay for the simple nosebleed 
treatment provided on April 1, 2020 billed with CPT code 30901.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck (76536) 
on February 7, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the head and neck. You say that the 
copayment should be waived because this service was medically necessary. 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 $100 
copayment for Medicare-covered diagnostic procedures and tests performed in an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for an ultrasound of the head and neck. An ultrasound of the 
head and neck 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 copayment for an ultrasound of the head and neck (76536) on 
February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on March 11, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says you do not meet Medicare coverage criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that for coverage for this orthosis there must be 
recent injury or surgery to the knee. The records show that you have knee pain. The record sent by your 
provider indicates that you have knee pain but your records do not demonstrate recent injury or surgery or that 
instability of your knee was found on physical exam. Therefore, we decided that the Plan does not have to pay 
for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits (99214 and 99215) 
on February 13 and February 28, 2020. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that the provider you saw on 
these dates of service is your primary care physician and should have a $0 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 defines the types of providers who may 
act as a primary care provider: family medicine doctors, general practitioners, internists, geriatricians, doctors 
in obstetrics/gynecology, nurse midwives, physician assistants, and nurse practitioners. Your contract with the 
Plan also clearly says that you must pay a $10 copayment for services obtained from a specialist.  
 
In this case, you have obtained services from an infectious disease provider. You have been asked to pay a $10 
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 
specialist office visits (99214 and 99215) on February 13 and February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on May 18, 2020

You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.

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 duplex scan provided on May 18, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace, right ankle brace, right heel stabilizer, left 
knee brace with suspension sleeve, left wrist brace, and right shoulder-elbow brace billed for date of service 
March 23, 2020. 
 
You asked the Plan to pay for the multiple braces. You say that all necessary documentation for payment of 
these items was submitted. The Plan denied your request. The Plan says there is no proof of delivery that 
matches the billed date of service. 
 
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 for the supplies provided in this case. Neither of the two 
delivery confirmations provided correspond to the billed date of service. 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 the back brace, right ankle brace, right heel stabilizer, left knee brace with suspension 
sleeve, left wrist brace, and right shoulder-elbow brace billed for date of service March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices and push-rim activated power 
assist devices are covered when specific criteria is met. 
 
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 a power scooter. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that you meet the coverage criteria for a heavy duty scooter due to your weight. A 
standard scooter appears to be appropriate for your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses billed to the enrollee for March 24, 2020. 
 
You asked the Plan to pay for this claim. You say that these orthoses should be covered by the Plan. The Plan 
denied your request. The Plan says there is not an itemized invoice or proof of delivery submitted with the 
claim. 
 
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 physician order or itemized and or 
detailed invoice for this claim. Therefore, we decided that the Plan does not have to pay for orthoses billed to 
the enrollee for March 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on March 17, 
2020 by an out of network provider. 
 
You asked the Plan to pay for domiciliary or rest home visit (99334). You say that the service was medically 
necessary. The Plan denied your request. The Plan says you did not request prior authorization and the service 
was not emergent or urgent. 
 
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 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 the service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit provided on March 17, 2020 by an out of network 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hydrochlorothiazide, Spironolacetone, and Potassium 
Chloride provided on March 9, 2020 and March 10, 2020. 
 
You asked the Plan to pay for the Hydrochlorothiazide, Spironolacetone, and Potassium Chloride. You say that 
while you were in the hospital, the nurse on duty gave you a drug and said you must take it yourself.  The Plan 
denied your request. The Plan says self-administered drugs are not covered in the observation hospital setting 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for the Hydrochlorothiazide, 
Spironolacetone, and Potassium Chloride provided on March 9, 2020 and March 10, 2020.  
 
Benefits for the Hydrochlorothiazide, Spironolacetone, and Potassium Chloride 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (J0475) provided March 10, 
2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be 
removed. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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 injections (J0475) provided 
March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are presently receiving these services in the short-term acute care setting. 
Continued care in the short-term acute care hospital is appropriate until you are stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 
facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the $49.94 copayment charged for urgent care 
services provided on August 2, 2019. 
 
You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is 
correct. The Plan denied your request. The Plan says this copayment is less than the normal contractual 
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 $65 
copayment for urgent care services.  
 
You have been asked to pay less than the normal copayment 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 or reduce the $49.94 copayment charged for urgent care services provided on 
August 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 12, 2019. 
 
You asked the Plan to pay for the physician's services. 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 
physicians services. 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 physician's services provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851), a suspension sleeve (L2397), and 
alcohol wipes (A4245) provided on March 19, 2020. 
 
You asked the Plan to pay for a knee orthosis, a suspension sleeve, and alcohol wipes. You say that these items 
were medically necessary. The Plan denied your request. The Plan says these items were ordered through a 
telehealth visit that does not meet coverage criteria. 
 
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 knee orthosis (L1851), a 
suspension sleeve (L2397), and alcohol wipes (A4245) provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95865, 95867) provided on April 
29, 2020. 
 
You asked the Plan to pay for needle electromyography. You say that the services provided clearly meet 
Medicare criteria. The Plan denied your request. The Plan says the records do not show these services were 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The submitted medical records are largely illegible and do not 
contain sufficient information to establish medical necessity. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the 
Plan does not have to pay for needle electromyography (95865, 95867) provided on April 29, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on April 23, 2020 
to April 24, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. 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 $120 
copayment for Emergency Room Services.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Room 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 emergency room visit on April 23, 2020 to April 24, 2020.