Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for needle electromyography. We decided that the Plan does not have to reduce the cost-sharing charges for needle electromyography to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for needle electromyography. You say that you disagree with the out-of-network charges. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for needle electromyography from $368.86 to $365. The Plan contract says that after the $350 deductible has been met, enrollee's must pay a $15 copayment for in-network and out-of-work diagnostic procedures and tests.
The Plan says that you must pay a $18.86 copayment for needle electromyography. However, the Plan contract says that you cannot be asked to pay more than a $15 copayment for diagnostic procedures and tests. Therefore, we decided that the Plan has to reduce the cost-sharing charges for needle electromyography from the total amount of $368.86 to $365.
We also decided that the Plan does not have to reduce the cost-sharing charges for needle electromyography to the amount you requested.
The Plan contract says that there is a $350 deductible for out-of-network services. The Plan contract also says that after the $350 deductible has been met, enrollee's must pay a $15 copayment for in-network and out-of-work diagnostic procedures and tests.
The record shows that you had paid $0 toward the $350 deductible prior to receiving the services. Therefore, you are responsible to pay the $350 deductible. Now that the deductible has been met, you are also responsible to pay the $15 copayment. The total amount you owe is: $365. Therefore, we decided that the Plan has to reduce the cost-sharing charges for needle electromyography to the amount you requested.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
physician?s 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 13, 2020. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 
service 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 a home visit provided on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory assist device provided on February 16, 2020 
and March 16, 2020. 
 
You asked the Plan to pay for the respiratory assist device. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 
item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for a respiratory assist device provided on February 16, 2020 and March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGeneSight Psychotropic testing (unlisted molecular pathology procedure) (CPT Code 81479) provided on July 20, 2020.You asked the Plan to pay forthe service. You say that the service is necessary.The Plan denied your request. The Plan says the service is not necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the service. Our physician reviewer found there are no clinical records in the case file to support that the coverage requirements for GeneSight Psychotropictesting were met in this case.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 service have not been met.Therefore, we decided that the Plan does not have to pay forGeneSight Psychotropic testing (unlisted molecular pathology procedure) (CPT Code 81479) provided on July 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for care in a SNF.The Plan denied your request. The Plan says SNF care is not supported by the records received. The Plan says that the enrollee's skilled needs can be met at the current inpatient rehabilitation facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a supervision/stand-by assist to minimal assist level with functional mobility, including gait to200 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee had ongoing left sided neglect. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93040) provided 
July 6, 2020. 
 
You asked the Plan to waive the copayment for the electrocardiogram. 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 $25 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay the Medicare allowable copayment of $12.27 for the electrocardiogram. The 
electrocardiogram falls within the outpatient diagnostic tests benefit category. The allowable amount is less 
than the $25 copayment noted in the plan contract. 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 (93040) provided July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 20, 2020. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 
home visit. 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 a home visit provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) provided on August 
5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this should not be considered out-of-
network The Plan denied your request. The Plan says this was not authorized 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 laboratory services (88305, 88312) provided 
on August 5, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a radiologic examination of hip (73525) 
performed on August 21, 2019. 
 
You asked the Plan to waive the copayment for a radiologic examination of hip. You say that the service 
rendered was mistakenly processed as a major diagnostic. 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 each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $75.27 copayment for a radiologic examination of hip. A radiologic examination 
of hip falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 
This means that you have been asked to pay less than or equal to 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 a radiologic examination of hip 
(73525) performed on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 
13, 2019, to November 15, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you met the MOOP 
amount for 2019 and should not be responsible for the copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from November 13, 2019, to November 15, 2019. The record shows that due 
to the reprocessing of claims, you had only paid $3,584.55 toward the $4,400 MOOP amount prior to receiving 
the services. Therefore, you are responsible to pay a $345 copayment for days 1-2 (November 13, 2019, to 
November 14, 2019). $345 (copayment) x 2 (inpatient days) = $690.  
 
You have been asked to pay the total copayment amount of $690 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from November 13, 2019, to November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 3, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings should be 
covered for you medical condition. The Plan denied your request. The Plan says compression stockings are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (A5501 and A5513) provided on June 3, 2020. 
 
You asked the Plan to pay for the orthotics. You say that you would like reconsideration because the billed 
supplies are medically necessary. The Plan denied your request. The Plan says the submitted documentation 
does not include a valid proof of delivery. 
 
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. Specifically, the 
proof of delivery does not include an itemized shipping or billing invoice to verify the billed supplies. 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 orthotics (A5501 and A5513) provided on June 3, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 
30, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says the date of service does not match the claim 
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. The claim date is 13 
days after the received date. 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 knee orthosis 
and suspension sleeve provided on January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on August 5, 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 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 on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite fillings (D2330, D2332) provided
on July 14, 2020.
You asked the Plan to pay for the fillings. You say that you were not aware of any limitations on your
coverage. The Plan denied your request. The Plan says you have exhausted your benefit limit for the 2020
calendar year.
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 the fillings
when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The file indicates that you have already received coverage for two
fillings you received in 2020 prior to the July 14, 2020 services you received. Based on this information, we
decided that the Plan's rules for coverage of the fillings have not been met. Therefore, we decided that the Plan
does not have to pay for the resin-based composite fillings (D2330, D2332) provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you feel that the charges are too 
high. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each visit with a specialist.

Therefore, you are responsible to pay the $40 copayment.   
 
Therefore, you are responsible to pay the $40 copayment.   
 
The total amount you owe is: $80.  
 
You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall within 
the physician/practitioner services, including doctors 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 copayments for specialist visits provided.
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 you need these services to help you regain your overall strength. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical performance test provided on August 24, 2020.You asked the Plan to waive the copayment forthe physical performance test. You say that you did not get physical therapy just a test.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 $40 copayment for Outpatient Rehabilitation services. You have been asked to pay a $40 copayment for the physical performance test. The physical performance test 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 forthe physical performance test provided on August 24, 2020.