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

 
We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test 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 laboratory 
services provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from July 12, 2021, to July 14, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were told to 
go to the hospital right away due to the possibility of blood clots. 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 $200 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $200 copayment for outpatient hospital observation. Outpatient hospital 
observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from July 12, 2021, 
to July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2021, to 
April 30, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. 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 (such as 
copayments, deductibles and coinsurance).  Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20 and a $184 
copayment for days 21-100 for SNF care.  
 
You had a SNF stay from March 17, 2021, to April 30, 2021. You are not being charged for days 1-20 (March 
17, 2021, to April 5, 2021). You are responsible to pay a $184 copayment for days 21-44 (April 6, 2021, to 
April 29, 2021). However, you are only being asked to pay $4,399.88, which is less than the total copayment 
amount.  
 
You have been asked to pay the total amount of $4,399.88 for a SNF stay. A SNF stay falls within the SNF 
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 a SNF stay provided from April 
1, 2021, to April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation services you 
received from June 18, 2020, to July 4, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that had you been 
in the skilled nursing facility, you would not have had a copayment.  You think your copayment should be 
waived or reduced because if you were in the skilled nursing facility, you would have received 2 therapy visits 
a day instead of 3. 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 $325 
copayment per day for days 1-5, and a $0 copayment per day for days 6-90 for inpatient rehabilitation.  
 You have been asked to pay a $325 copayment per day for days 1-5, and a $0 copayment per day for days 6-90 
for the inpatient rehabilitation services. This copayment applies regardless of what benefits may have been 
available to you without cost sharing at a skilled nursing facility.  You did not receive skilled nursing facility 
services- you received inpatient rehabilitation services. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
acute inpatient rehabilitation services you received from June 18, 2020, to July 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from 
June 15, 2021, to June 26, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you were admitted to 
the hospital and should not be responsible for 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received outpatient hospital services from June 15, 2021, to June 26, 2021. Therefore, you are responsible to pay the $350 copayment. Please note, outpatient hospital charges are less than inpatient hospital charges and 
this is in your financial favor.   
 
You have been asked to pay a $350 copayment for outpatient hospital services. Outpatient hospital services fall 
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 copayment for outpatient hospital services 
provided from June 15, 2021, to June 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from March 19, 2021, through  
April 17, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says that the member's  
100-day skilled nursing facility benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 18, 2020, 
through February 13, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for SNF services provided from March 19, 2021, through April 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the lower extremities you received on May 18, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that you cannot afford this copayment. 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 $125 copayment for radiological diagnostic services. 

You have been asked to pay a $125 copayment for the duplex scan. The duplex scan falls within the radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex scan of the lower extremities you received on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided 
on June 4, 2021. 
 
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
 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, we have confirmed that code 70450 
for the CT scan is a column II code to column I code 70496. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 
provided on June 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a Hyalgan injection. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan does not cover non-emergency services by a non-contracted provider 
when a contracted provider can do the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a Hyalgan injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 7, 2021.  You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 out of network physician services provided to the enrollee on July 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 9, 2020.

You asked the Plan to pay for laboratory testing. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory testing provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have recently received a homefill and 
stationary concentrator. The Plan says a Homefill is a system used to fill tanks at home using a stationary 
concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Homefill using D-Tanks. A Homefill using D-Tanks serves the same purpose as 
a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on May 10, 2021. 
 You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says no new 
medical records were provided. The documentation submitted on appeal consists of duplicates of medical 
documents previously reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a 
physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to 
requirements must be met, even though the service is provided by a licensed therapist who may perform the 
services unsupervised in other settings. 
 
We looked at the file and Medicare rules. The file shows that the therapeutic activities were billed by an NPP 
and rendered by a PT. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the out-of-network dermatology services 
you received on March 10, 2021. 
 
You asked the Plan to waive the copayment for the out-of-network dermatology services. You say that you 
have seen this provider in the past and the claims have always been paid as in-network. 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 $60 
copayment for out-of-network specialist visits.  
 
You have been asked to pay a $60 copayment for the out-of-network dermatology services. The out-of-network 
dermatology services falls within the out-of-network specialist visits benefit category. This out-of-network cost 
sharing applies regardless of how claims may have been paid in the past. 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 out-of-network dermatology services you received on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
11, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were 
provided as part of an annual wellness exam so you should not owe anything. 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 $10 copayment for laboratory services. 
 
You received laboratory services on February 11, 2020. Laboratory services are not included in annual 
wellness exams. Therefore, you are responsible to pay the $10 copayment.   
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 30, 2021. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were not informed of the 
charges prior to receiving them. 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 $395 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The medical records show that you received a diagnostic colonoscopy on July 30, 2021. Therefore, you are 
responsible to pay the $395 copayment.  
 
You have been asked to pay a $395 copayment for a colonoscopy. A colonoscopy 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 copayment for a colonoscopy provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Avastin injection you received on 
April 14, 2021. 
 
You asked the Plan to waive the coinsurance for the Avastin injection. You say that you were never told there 
would be an additional charge to get this shot in your eye. The Plan denied your request. The Plan says you 
were charged this coinsurance 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Avastin injection. The Avastin injection falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Avastin 
injection you received on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on July 14, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services should be 
considered part of your annual physical. The Plan denied your request. The Plan says these lab services are not 
part of a routine physical, so the copayment applied 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the lab services. Your contract does not say that an annual 
physical includes lab services and that no separate cost sharing applies. 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 lab services you received on July 14, 2021.