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

We decided that the Plan does not have to pay for wound care services provided to the enrollee on August 13,
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 services were not authorized by network/primary care providers.
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 wound care services provided to the enrollee on
August 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May
11, 2021 to May 31, 2021.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate
type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim
was submitted with type of bill code 323. This is not a valid type of bill code for home health services.
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee
from May 11, 2021 to May 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance imaging (70551) provided on August 11, 2021.
You asked the Plan to pay for code 70551. 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 as billed.
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 70551 is a column II code to column I code 70552. 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 Magnetic resonance imaging (70551) provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wrist-hand orthosis provided on May
11, 2021.
You asked the Plan to waive the coinsurance for the wrist-hand orthosis. You say that you were told the splint
would be covered by your insurance. 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 20%
coinsurance for all other Medicare-covered prosthetic or orthotic devices, including replacement or repairs of
such devices, and related supplies.
You have been asked to pay $77.50 which is 20% of the allowed amount for the wrist-hand orthosis. The
allowed amount is $387.48. ($387.48 x 20% = $77.50). The wrist-hand orthosis falls within "Prosthetic
Devices and Related 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
the wrist-hand orthosis provided on May 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; diagnostic
(45378) provided on September 15, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel that this
should have been coded as preventative, not diagnostic. The Plan denied your request. The Plan says the
copayment was 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 $175
copayment for each Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $175 copayment for the diagnostic colonoscopy. The medical record provided
indicates that the colonoscopy was performed for cancer surveillance due to a history of colon cancer and
history of colon polyps. This means that the colonoscopy was correctly billed as a diagnostic colonoscopy. The
diagnostic 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 the colonoscopy, flexible; diagnostic (45378) provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical office note does not corroborate the findings described in the mobility evaluation written by the occupational therapist.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided from the enrollee's treating medical provider (08/16/2021 visit note) there is no documentation that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the
home. The records from the enrollee's treating medical provider report she has a normal gait with no weakness. There is no documentation that the mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate tablets.

You asked the Plan to pre-approve the Methotrexate tablets. The Plan denied your request. The Plan says Methotrexate tablets are a self-administered drug which falls under Part D coverage.

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 Methotrexate tablets.

Benefits for the Methotrexate tablets 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound (76705) provided
on July 29, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 Medicare covered radiological diagnostic services, not including x-rays, performed in a
physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $58.64 copayment for the Medicare-covered radiological diagnostic service
provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 abdominal ultrasound (76705) provided on July 29,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled
therapy services on a daily basis in an inpatient 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 SNF care have not been met. Specifically, medically necessary services can be
obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the skilled
nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic radiology services (77263)
provided on August 15, 2021.
You asked the Plan to waive the copayment for the therapeutic radiology services. You say that the services
should be covered as you were informed by the provider that they would waive your cost-sharing. The Plan
denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a 20% coinsurance for therapeutic radiology services (the allowed amount is
$173.17 x205 = $34.63). Therapeutic radiology 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
therapeutic radiology services (77263) provided on August 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided
on May 28, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the Medicare-covered emergency room visit provided. 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 emergency room visit (99284) provided on
May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sleep number bed provided on July 4, 2021, provided by
a non-Medicare enrolled provider.

You asked the Plan to pay for the sleep number bed. 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 when provided by
a provider who has not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the sleep number bed provided on July 4, 2021, provided by a non-Medicare enrolled provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on August 10, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for x-rays and a magnetic resonance imaging
(MRI) provided from May 14, 2021, to May 27, 2021
You asked the Plan to waive the copayments for x-rays and an MRI. You say that the services rendered were
not in an outpatient hospital but an independent testing facility outside of the hospital. The Plan denied your
request. The Plan says the services provided was at an In-Network outpatient hospital and the proper
copayments have been 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 $150
copayment for X-rays when performed in an Outpatient Hospital Facility and a $110 copayment for Advanced
Imaging Services are provided in an outpatient hospital facility. On May 14, 2021, and May 27, 2021, the total
amount allowed for each date was $98.55 which is less than the copayment amount of $150. Therefore only
$98.55 was charged for the copayment on each date with a total of $197.10 ($98.55 copayment + $98.55
copayment). On May 20, 2021, the total amount was $208.12 with a copayment of $110.
You have been asked to pay a total of $307.10 copayment for x-rays and an MRI. X-rays and an MRI 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 copayments for x-rays and a magnetic resonance imaging (MRI) provided from
May 14, 2021, to May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on June 5, 2021, and June 6, 2021.
You asked the Plan to waive the copayments for the specialist office visits. You say that these services were performed while you were in the hospital and there should be no charge. 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 $15 copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $15 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows the visits were provided at an outpatient hospital. 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 specialist office visits provided on June 5, 2021, and June 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anal lesion destruction (46924), the cervical or vaginal
cancer screening; pelvic and clinical breast examination (G0101), the handling and/or conveyance of a
specimen for transfer from the office to a laboratory (99000), and the screening of a papanicolaou smear;
obtaining, preparing and conveyance of a cervical or vaginal smear to laboratory (Q0091) rendered by the out-
of-network (OON) provider on September 14, 2021.
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the anal lesion destruction (46924), the cervical or vaginal cancer screening;
pelvic and clinical breast examination (G0101), the handling and/or conveyance of a specimen for transfer
from the office to a laboratory (99000), and the screening of a papanicolaou smear; obtaining, preparing and
conveyance of a cervical or vaginal smear to laboratory (Q0091) rendered by the out-of-network (OON)
provider on September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound of the abdomen and
retroperitoneum and a pelvic ultrasound provided on July 20, 2021.
You asked the Plan to waive the copayment for a diagnostic ultrasound of the abdomen and retroperitoneum
and a pelvic ultrasound. The Plan denied your request. The Plan says allowed amount is lower than the
member's copayment amount of $155.00.
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 $155
copayment for other outpatient diagnostic tests -radiological diagnostic services, not including x-rays.
You have been asked to pay the allowed amount copayment for a diagnostic ultrasound of the abdomen and
retroperitoneum and a pelvic ultrasound. A diagnostic ultrasound of the abdomen and retroperitoneum and a
pelvic ultrasound falls within the other outpatient diagnostic tests -radiological diagnostic services, not
including x-rays. 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 diagnostic
ultrasound of the abdomen and retroperitoneum and a pelvic ultrasound provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visits (9213) provided on August 5, 2021, and October 5, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you were seen by your primary care provider. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $60 copayment for two specialist office visits. The record indicates that your primary care physician is a dual specialist, and you have a medical condition related to their specialty that you are being seen for. 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 specialist office visits (9213) provided on August 5, 2021, and October 5, 2021