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

 
We decided that the Plan does not have to pay for laboratory services provided on June 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you did not know authorization was needed 
to see out-of-network providers. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to services being rendered. 
 
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 laboratory services provided on June 23, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing on June 03, 2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Covered 
services include but are not limited to laboratory and diagnostic tests billed by the hospital. 
 
You have been asked to pay a $5 copayment for lab testing. This item/service falls within the Outpatient 
hospital 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 lab testing on June 
03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 26, 
2022, to March 9, 2022 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says medical necessity has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found it was not expected that the enrollee would require hospital services that would cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 26, 2022, to March 9, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 27, 2020, to April 30, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that although it is documented that 
the enrollee was taken to the operating room for surgery, the case file does not document that the enrollee 
received skilled nursing treatment of extensive or complex wounds. The only treatment was the discharge 
instructions noting "Keep lower extremity wounds clean and dry." 
 
We looked at this 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 skilled nursing facility (SNF) services provided to the enrollee from April 27, 2020, to April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on July 5, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you do not understand why the refraction was 
denied. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed 
by a participating provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you did not receive a routine eye exam, but 
instead received a medical exam for the diagnosis of Age-related nuclear cataract, bilateral. Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the eye refraction provided on July 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT), of the abdomen and pelvis; 
with contrast material(s) (74177), computed tomographic angiography (CTA), of the chest (noncoronary), with 
contrast material(s), including non-contrast images, if performed, and image postprocessing (71275), and  
the computed tomography (CT), of the head or brain; without contrast material (70450) provided on April 3, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on June 15, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT), of the abdomen and pelvis; 
with contrast material(s) (74177), computed tomographic angiography (CTA), of the chest (noncoronary), with 
contrast material(s), including non-contrast images, if performed, and image postprocessing (71275), and  
the computed tomography (CT), of the head or brain; without contrast material (70450) provided on April 3, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
November 01, 2021, to November 06, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you say that 
you cannot afford the cost share because you are on a fixed income. The Plan denied your request. The Plan 
says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $184 copayment per day for days 21-100 for skilled nursing facility (SNF) care. Plan covers up to 
100 days each benefit period. No prior hospital stay is required. From October 07, 2021, to October 31, 2021, 
there is a $0 copayment per day. From November 01, 2021, to November 06, 2021, there is a $184 copayment 
per day. There were 5 days. 5 x $184 = $920. Therefore, results in the total cost sharing amount of $920.  
 
 
 The enrollee has been asked to pay a $184 copayment per day for skilled nursing facility (SNF) care. This 
item/service falls within the Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care on November 01, 2021, to November 06, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) mask 
provided on June 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP mask. You say that the network provider could not be reached. The 
Plan denied your request. The Plan says authorization was not obtained prior to services being rendered, and a 
network provider had the mask in stock. 
 
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 a continuous positive airway pressure (CPAP) 
mask provided on June 23, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were provided within the service area 
and should be paid. The Plan denied your request. The Plan says a referral/authorization was not obtained prior 
to services being rendered. 
 
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 July 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided from 
November 4, 2021, to November 6, 2021. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you would like to be 
reimbursed for some of these medical charges you were required to pay. The Plan denied your request. The 
Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance service from an institution to the 
beneficiary's home is covered when the home is within the locality of such institution.  
 
We looked at the file and Medicare rules. Specifically, because this transportation was a result of an event that 
happened while you were on vacation, your home is not local to the hospital, and the hospital was not the 
nearest appropriate facility to your home. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for the non-covered ambulance mileage (A0888) provided from November 4, 2021, to 
November 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
July 19, 2022. 
 
You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you feel the AAA should be 
covered in full as per your benefit coverage. The Plan denied your request. The Plan says this benefit has been 
exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA).  
 We looked at the file and Medicare rules. The record shows that you received an ultrasound of the abdominal 
aorta (76706) on January 26, 2018, and your AAA benefit has been exhausted. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound of the abdominal aorta have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) 
provided on July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cataract surgery provided on May 20, 
2022. 
 
You asked the Plan to waive the coinsurance for the cataract surgery. You say that cataract surgery should be 
fully covered. The Plan denied your request. The Plan says this cost sharing was charged 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 18% 
coinsurance for surgery services at an outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay 18% coinsurance for the cataract surgery. This item/service falls within the 
surgery services at an outpatient hospital or ambulatory surgical center 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 cataract surgery provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and the copayment for the injections and the 
specialist office visit provided on June 16, 2022. 
 
You asked the Plan to waive the coinsurance and the copayment for the injections and the specialist office visit. 
You say that you have never paid for these services before. The Plan denied your request. The Plan says this 
cost sharing was charged 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 20% 
coinsurance for in-network Medicare Part B covered drugs in a specialist's office and a $45 copayment for in-
network surgery services in a specialist's office. The total amount allowed for the injection was $154.75 with a 
coinsurance amount of $30.95 ($154.75 total amount allowed x 20% coinsurance). 
 You have been asked to pay a $30.95 coinsurance for the injections and a $45 copayment for the specialist 
office visit. The injections fall within the in-network Medicare Part B covered drugs in a specialist's office 
benefit category. The specialist office visit falls within the in-network surgery services in a specialist's office 
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 and the copayment for the 
injections and the specialist office visit provided on June 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on January 3, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the admission was denied because the enrollee was not ill and required an admission 
physical. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the patient 
required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The 
records did not document the need for intravenous medications, new tube feeding or ostomy care or daily 
complex wound care or respiratory care. Although the records report the patient was weak, the medical records 
provided contain inadequate documentation to clarify if this patient required skilled therapy services (or that, 
with her level of dementia, she was able to participate with skilled therapy). It cannot be told that skilled 
services were required. There is inadequate documentation that this patient required the services on an inpatient 
basis, only in a skilled nursing facility 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. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee on January 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 25, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the member did not know about the 
copayment. The member didnt receive anything but a $100 bill from the hospital that did not explain what it 
was for. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service 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 an ultrasound provided on March 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on June 
17, 2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you told the providers 
office on June 17, 2022, to cancel the June 24, 2022 appointment. You say you received a bill and were 
charged for the June 24 appointment and you feel that is not right because you didnt go. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy services. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy services provided on June 17, 2022, to June 24, 2022.