Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D6058) provided December 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that the service was medically necessary and should 
be covered. The Plan denied your request. The Plan says the dental benefit was exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the plan's benefit is limited to $2,500 a 
year. The enrollee is responsible for the remaining $233. Therefore, we decided that the Plan does not have to 
pay for dental services (D6058) provided December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (CPT E0676). 
 
You asked the Plan to pre-approve an intermittent limb compression device. 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. Medicare rules say that items that are used for a preventative service or 
function are excluded from coverage under the Medicare DME benefit  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an intermittent limb compression device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intermittent limb compression device (CPT E0676).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on December 2, 
2021. 
 
You asked the Plan to waive the copayment for the laryngoscopy. You say that you had already met your out-
of-pocket maximum in July and your copays should be waived. The Plan denied your request. The Plan says 
the copayment applied 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 a $50 
copay for diagnostic tests at a specialist's office.  
 
The Claim Receipts show that you had not hit your out-of-pocket maximum prior to this service.  
 You have been asked to pay a $50 copay for the laryngoscopy. The laryngoscopy 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 the laryngoscopy provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that it was medically necessary to treat the enrollee and 
the enrollee's primary care physician (PCP) could not provide a referral because they have not seen them. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
approved authorization. Also, communication was made with the enrollee's PCP, and they advised they did not 
refer the enrollee to the out-of-network provider. The service rendered was also 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 April 23, 2021, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq. 
 
You asked the Plan to pre-approve Rinvoq. You say that you would like reconsideration because this drug is 
medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says this drug is 
not covered 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 pre-approve Rinvoq.  
 Benefits for Rinvoq 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for 
transfer to a lower level of care. There are no services at the LTACH that you require that are not already 
available at the current facility. Transfer may be considered when treatment has completed and you are more 
stable with more permanent feeding source. 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided by a network facility from August 18, 2021, to September 11, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the service was due to medical 
error, not for a planned surgery. You say you feel like you should not have to pay this bill. The Plan denied 
your request. The Plan says you have been asked to pay 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 $0 
copayment per day, per admission for days 1-20 and a $100 copayment per day, per admission for days 21-100.  
 
 You have been asked to pay a $400 copayment for the SNF stay. The SNF stay falls within the Skilled nursing 
facility (SNF) care benefit category. See chart below. 
 
Dates of Service Service SNF Days Copayment Day Count Member Liability 
August 18, 2021, to 
September 6, 2021 
SNF stay 1-20 $0 20 $0 
September 7, 2021, to 
September 11, 2021 
SNF stay 21-25 $100 4 $400 
Total     $400 
 
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 skilled nursing facility (SNF) stay provided by a 
network facility from August 18, 2021, to September 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance's for the outpatient surgeries provided on 
March 4, 2020, and December 30, 2020. 
 
You asked the Plan to waive the coinsurance's for the outpatient surgeries. You say that you were told the 
wrong information and would like the Plan to waive the coinsurance. The Plan denied your request. The Plan 
says the proper coinsurance was applied for each date of service. 
  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 surgery performed at an Outpatient Hospital Facility. On March 4, 2020, the total amount 
allowed was $9,769 with a coinsurance of $1,953.80 ($9,769 total amount x 20% coinsurance). On December 
30, 2020, the total amount allowed was $9,454.87 with a coinsurance of $1,890.97 ($9,454.87 total amount x 
20% coinsurance). The total amount of coinsurance for both dates of service was $3,844.77 ($1,953.80 
coinsurance + $1,890.97 coinsurance). 
 
You have been asked to pay a $3,844.77 coinsurance for the outpatient surgeries. The outpatient surgery falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance's for the outpatient surgeries 
provided on March 4, 2020, and December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 10, 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 denied services are inclusive to other services. 
 
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 the denied codes is: 
 
CPT 25295: 
 
Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon 
 
CPT 20680: 
 
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 
 We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 25295, the operative 
report describes a tendolysis performed during a open reduction, internal fixation of radial shaft fracture. This 
procedure would be inclusive to the more extensive procedure performed, and not separately reported. In terms 
of CPT 20680, the operative report describes hardware removal, and replaced during open reduction and 
internal fixation (ORIF). Removal of hardware would be inclusive to ORIF. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on April 10, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for cancer testing provided on November 21, 2020. 
 
You asked the Plan to pay for cancer testing. You say that the services were referred by the enrollees treating 
physician. The Plan denied your request. The Plan says that the services were not medically necessary. 
 
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 has not provided information identifying the ordering physician as an 
in-network or out-of-network provider. Without this information, we cannot determine whether the lab order 
made constituted plan-directed care. Thus, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
cancer testing provided on November 21, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health evaluation provided on 
May 27, 2021 
 
You asked the Plan to waive the copayment for the mental health evaluation. You say that you did not 
authorize this doctor's appt. The Plan denied your request. The Plan says the copayment applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copay for each in-person outpatient mental health or outpatient psychiatric individual therapy 
visit.  
 
 The enrollee has been asked to pay a $20 copay for the mental health evaluation. The mental health evaluation 
falls within the Outpatient mental health care benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the mental health evaluation provided on May 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on November 8, 2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that the providers office told you they 
were in-network. The Plan denied your request. The Plan says the deductible has not been met. 
 
At the time this service was provided, this provider was not in network. 
 
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 $750 deductible which must be met before the Plan will begin to pay 
its share. The allowed amount of this claim is $94.83, resulting in a deductible amount of $94.83. 
 
 
  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. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible which applies to out-of-network doctor's office 
visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was 
received on November 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
the office visit on November 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biospecimen procurement services provided to the enrollee 
on November 8, 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 enrollee was in hospice at the time of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for biospecimen procurement services provided to the enrollee 
on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for infusion supplies you received from a network provider on from July 
11, 2021, to July 15, 2021. 
 
You asked the Plan to pay for the infusion supplies. You say that you do not understand why this claim was not 
paid. The Plan denied your request. The Plan says that these items were not authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
Records show that the vendor from whom you receive the infusion supplies is a contract provider with your 
Plan. The file does not show that the Plan provided notice that the infusion supplies would not be covered. 
Under Medicare rules, this means the infusion supplies is considered approved by the Plan. Therefore, we 
decided that the Plan has to pay for infusion supplies you received from a network provider on from July 11, 
2021, to July 15, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the surgical services provided on October 
7, 2021, October 12, 2021, October 19, 2021, and October 26, 2021 
 
You asked the Plan to waive the copayments for the surgical services. You say that you did not have any 
surgery and the billing is wrong. The Plan denied your request. The Plan says the services were performed in a 
hospital outpatient department within the hospital which allows for both facility and physician charges. 
Therefore, the proper copayments were 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 $250 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. On 
October 7, 2021, you were charged a $250 copayment. On October 12, 2021, you were charged a $250 
copayment. On October 19, 2021, you were charged a $250 copayment. On October 26, 2021, you were 
charged a $250 copayment. The total amount of the copayments combines is $1,000 ($250 copayment x 4 dates 
of service). 
 
You have been asked to pay a $1,000 copayment for the surgical services. The surgical services falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the surgical services 
provided on October 7, 2021, October 12, 2021, October 19, 2021, and October 26, 2021
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for fundus photography provided on 
November 12, 2021. 
 
You asked the Plan to waive the coinsurance for fundus photography. You say that you should only be 
responsible for a $35 copayment for your annual diabetic retinopathy screening. You also say that you had 
fundus photography last year and you only had to pay your regular copayment for the screening. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan also says 
that your benefits in 2020 were different than your benefits in 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 20% 
coinsurance for diagnostic testing, including fundus photography.  
 The Plan confirmed that your cost sharing benefits were different in 2020 than they were in 2021. According to 
Medicare, Fundus photography is a separately billable service when provided by a physician. You have been 
asked to pay $9.09, which is 20% of the allowed amount for each date ($45.47 allowed amount x 20% 
coinsurance = $9.09). Fundus photography 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 coinsurance for fundus 
photography provided on November 12, 2021.  
 
Your complaint about the way the policy is written is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.