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

 
We decided that the Plan does not have to pay for the nursing facility care provided on November 5, 2021, 
November 8, 2021, and November 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
were numerous in-network providers that provide the same service. 
  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 had network providers 
available who could have provided 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 nursing facility care provided on November 5, 
2021, November 8, 2021, and November 19, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home visit services provided on October 1, 2021 to October 
6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home visit services. You say that you would like to appeal the denial of the 
claim an that a referral was acquired The Plan denied your request. The Plan says the provider is out-of-
network and it was determined these services were not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Home visit services provided on October 1, 2021 
to October 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist telehealth visits provided on 
January 7, 2022, and February 8, 2022. 
 
You asked the Plan to waive the copayments for the specialist telehealth visits. You say that you cannot afford 
the copayments. 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 $50 
copayment for specialist services, including telehealth.  
 
You have been asked to pay a $50 copayment for each of the specialist telehealth visits, for a total of $100. The 
specialist telehealth visits fall 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 copayments for specialist telehealth visits 
provided on January 7, 2022, and February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that COVID-19 numbers 
were high so you chose telehealth for your protection. 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 $30 
copayment for each specialist telehealth visit.  
 
You have been asked to pay a $30 copayment for the specialist telehealth visit. The specialist telehealth 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 a specialist telehealth visit provided on November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 6 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 an additional 6 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 6 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 6 physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the physician is a qualified pain specialist, and he 
should be paid for his services. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 an office visit provided on November 8, 2021, by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee's rehabilitation does not require an intensive team approach. The Plan says that the enrollee's needs 
can be met 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee from 
September 17, 2021, to September 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not include the time spent providing this service. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a 
time-based code. 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 critical care services provided to the 
enrollee from September 17, 2021, to September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that an authorization was 
required to see the OON provider. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 had network providers 
available who could have provided 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 an office visit provided on December 30, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy provided on November 17, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 Psychotherapy provided on November 17, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that previous claims have been paid and you 
would like for this claim to be reprocessed for payment. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no referral from an in-network 
provider. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 provided on January 18, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay from January 19, 2022 to 
January 22, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were discharged too soon 
resulting in re-admission. You say that you are requesting that the copayment be covered by the plan. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 $295 
copayment each day for days 1-5 for Medicare-covered hospital care each time you are admitted. $0 copayment 
for additional Medicare-covered days.   
You have been asked to pay a total of $885 ($295 x 3 days = $885) for the inpatient stay. The inpatient stay 
falls within 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 stay from January 19, 2022 to January 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on September 27, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that authorization should have been 
obtained by the facility or referring physician. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
 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 had network providers 
available who could have provided 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 skilled nursing facility services provided on 
September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit provided on 
January 19, 2022, and February 2, 2022.  
 
You asked the Plan to waive the copayments for a specialist office visit. You say that you called the Plan and 
were told that the doctor was in-network so you thought that meant there would be no copayments. 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 $45 
copayment for each specialist office visit. 
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $45 copayment for each specialist office visit on January 19, 2022, and February 2, 2022. A specialist office visit falls 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 a specialist office visit provided on January 19, 2022, and 
February 2, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the surgery provided on January 5, 2022. We decided 
that the Plan does not have to waive the copayment for surgery provided on December 13, 2021.  
 
You asked the Plan to waive the copayment for the surgeries. You say that you have been going to this clinic 
since 2018 and they told you that there is no copayment. You say that you don't know why you have to pay a 
copayment. The Plan says that you have been charged the correct copayment amounts. 
 
We decided that the Plan has to waive the copayment for post cataract laser surgery provided on 
January 5, 2022.  
 
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 says you must pay $150 copayment for surgery. The Plan has not 
provided a copy of the Evidence of Coverage applicable to date of service January 5, 2022. Without the 
applicable Evidence of Coverage, we cannot determine whether the $150 copayment that you have been asked 
is correct based on your contract with the Plan. Therefore, the Plan has not shown that its decision to ask you to 
pay $150 copayment for this surgery is correct or justified according to Medicare rules and the Plan contract. 
Therefore, we decided that the Plan has to waive the copayment for the surgery provided on January 5, 2022.  
 
We also decided that the Plan does not have to waive the copayment for surgery provided on December 
13, 2021. 
 
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 $150 
copayment for each visit to an outpatient hospital facility. Therefore, we decided that the Plan does not have to 
waive the copayment for surgery provided on December 13, 2021. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 10, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you paid for labs on a 
different claim for the same day, so you should not have to pay this again. The Plan denied your request. The 
Plan says coinsurance 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 $10 
copayment per day, per provider, for Medicare-covered in-network lab services.  
 
  You have been asked to pay $8.07, which is less than the standard $10 copayment for laboratory services. 
Laboratory services 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 laboratory services provided on January 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the $75 Over-the-Counter (OTC) benefit from the first 
quarter of 2022 to carry over to the second quarter. 
 
You asked the Plan to pre-approve the $75 OTC benefit from the first quarter of 2022 to carry over to the 
second quarter. You say that you feel that if you had been given the specific information, you would not have 
lost your first quarter allocation. The Plan denied your request. The Plan says the over-the-counter quarterly 
allotment of $75.00 must be used within the quarter it was allocated. The Plan also says that the allotment 
cannot be carried over to the next quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, but your plan 
allows a $75 quarterly allowance for OTC items. The contract clearly states that the $75 quarterly allowance 
cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to pre-approve the 
$75 Over-the-Counter (OTC) benefit from the first quarter of 2022 to carry over to the second quarter.