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

We decided that the Plan does not have to waive the deductible for an office visit and does not have to waive the coinsurance for chemotherapy provided from February 11, 2020 to February 28, 2020.
You asked the Plan to waive the deductible for an office visit and to waive the coinsurance for chemotherapy. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $390 deductible. Your contract with the Plan also says that after the $390 deductible has been met, enrollee's must pay 10% coinsurance for Medicare Part B prescription drugs. You had an office visit on February 11, 2020. The record shows that you had only paid $362.35 toward the $390 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $27.65. You received chemotherapy drugs on February 28, 2020. The allowed amount is $422.40 and 10% of that is $42.24. The total amount you owe is: $69.89. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits and Medicare Part B prescription drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $390 deductible for physician/practitioner services, including doctor's office visits and Medicare Part B prescription drugs. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on February 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an office visit and does not have to waive the coinsurance for chemotherapy provided from February 11, 2020 to February 28, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the abdominal x-ray provided on March 13, 2020 
by the non-contract provider. 
 
You asked the Plan to pay for the abdominal x-ray interpretation. You say that these are billed correctly and 
should be paid separately. The Plan denied your request. The Plan says that there is a PTP edit and code 74019 
can never be billed on the same date as 74022. 
 
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. In this case, the Plan has indicated that a PTP edit exists between a code billed 
by the provider in this case and another radiologist. This is not appropriately applied as the services were not 
provided by the same physician. In addition, the appeal request from indicates that records were submitted but 
they are not included and of the 8 pages noted to be in the file, two pages are missing, both 5/8 and 6/8. Based 
on these deficiencies, we find that the denial of payment is not supported in this case. Therefore, we decided 
that the Plan has to pay for the interpretation of the abdominal x-ray provided on March 13, 2020 by the non-
contract provider.  
 
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 deductible for an office visit provided on February 10, 
2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $198 deductible for primary care provider visits.  
 
You had an office visit on February 10, 2020. The record shows that you had paid $0 toward the $198 
deductible prior to receiving the service. Therefore, you are responsible to pay the allowed amount of $76.10. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Medicare 
Part B deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$198 deductible for primary care provider visits. This cost sharing is a contractual obligation that had not been 
met at the time an office visit was received on February 10, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for an office visit provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lumbar-sacral orthosis (L0650) provided February 20, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says there is no actual physical exam and 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 is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. There is no evidence of an established relationship between the enrollee and the 
ordering physician. 
 
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 Lumbar-sacral orthosis 
(L0650) provided February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) and trifocal lenses (V2300) provided December 8, 2019.
You asked the Plan to pay for the vision services. You say that you were in need of and had gotten a change in lens correction and wanted to have new sun glasses that are appropriate updated vision script for the new glasses. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider and this request exceeds the plan benefit limit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every 2 years and when the services are rendered by an in-network provider.
We looked at the file and the Plan's rules. The Plan covers these services once every 2 years and when the services are rendered by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) and trifocal lenses (V2300) provided December 8, 2019.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services after February 10, 2020. 
 
You asked the Plan to pay for SNF care. 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 that there is no clear benefit of 
inpatient skilled nursing as opposed to an alternative setting for care. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before February 10, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services after February 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist surgery rendered on January 22, 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 procedure code 29848 is not supported. 
 
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 29848 is endoscopy, wrist, surgical, with release of 
transverse carpal ligament. 
 
We find that CPT code 29848 is not supported in the medical record. Specifically, the code was billed with -79 
and was not billed with a related original surgical procedure with a global surgical period. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the wrist surgery rendered on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient lab work provided on February 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not 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 outpatient lab work provided on February 20, 
2020 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 stent removal procedure provided on 
March 17, 2020. 
 
You asked the Plan to waive the copayment for the stent removal procedure. You say that you do not feel like 
you should have to pay a second copayment for this procedure. You say the first doctor was unable to remove 
the stent. 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 $400 
copayment for an outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for the stent removal procedure. The stent removal procedure 
falls within the Outpatient hospital services benefit category. The record shows you received surgery on this 
date of service. 
 
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 stent removal procedure provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-contact normothermic wound therapy (NNWT) provided 
to the enrollee on March 27, 2020. 
 
You asked the Plan to pay for the NNWT. You say that the medical records should be reviewed, and payment 
should be issued. The Plan denied your request. The Plan says this service is considered experimental and 
investigational for this diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that NNWT is not a covered service.  
 
The service at issue in this case is statutorily not covered. Based on this information, we decided that Medicare 
rules for coverage of the NNWT have not been met. Therefore, we decided that the Plan does not have to pay 
for non-contact normothermic wound therapy (NNWT) provided to the enrollee on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were not told that the services wouldn't be 
covered. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider 
without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 May 5, 2020 by 
an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for emergency services 
provided on a cruise ship on February 18, 2020. 
 
You asked the Plan to reimburse you an additional amount for the emergency services. You say that you would 
like to be reimbursed in full for the emergency services you received. The Plan denied your request. The Plan 
says the Plan is only responsible for reimbursement according to contracted rates, and the Plan has already 
provided this reimbursement. 
 
The rules say  
 
We looked at your request, the file and rules. Based on this information, we decided that Medicare rules for full 
reimbursement of the emergency services have not been met. Specifically, the Plan is only responsible to 
reimburse you for covered out-of-network emergency and urgent care services outside of the U.S. and its 
territories, at rates no greater than the rates at which Original Medicare would pay for such services had the 
services been performed in the United States in the locality where you reside. Additionally, CPT codes 36000 
and 99070 are bundled codes. Payment for these services is included in another service provided at the same 
time. Therefore, we decided that the Plan does not have to reimburse you an additional amount for emergency 
services provided on a cruise ship on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on March 9, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on September 24, 
2019. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the cost of this service is similar to the 
cost of a prophylaxis, which is a covered benefit. You also say that there is clinical need for the periodontal 
maintenance. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 pay for the 
periodontal maintenance provided on September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from 
November 4, 2019 to December 13, 2019. 
 
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not 
informed that you would have a copayment for the therapy. 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 $40 
copayment for physical therapy services.  
 
You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy 
visits fall 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 copayments for the physical therapy visits provided from November 4, 2019 to December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back orthotic (L0650) provided March 
16, 2020. 
 
You asked the Plan to waive the coinsurance for the back orthotic. You say that the coinsurance should be 
waived. The Plan denied your request. The Plan says the correct coinsurance was applied in this case. 
 
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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the back orthotic. The back orthotic falls within the durable 
medical equipment 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 a back orthotic 
(L0650) provided March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from February 15, 2019
to March 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered from February 15, 2019 to March 25, 2019.
Benefits for these services 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the oxygen concentrator provided on March 7, 2020. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you are being charged 
in error. You say you are not going to pay for a piece of equipment that you were never provided. The Plan 
denied your request. The Plan says that you have been charged the correct cost sharing 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 did not submit any documentation to support that you had received the 
oxygen concentrator. Therefore, the plan has not shown that the coinsurance amount you are being asked to pay 
is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the 
coinsurance for the oxygen concentrator provided on March 7, 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.