Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient hospital care on September 30, 
2021 to October 5, 2021. 
 
You asked the Plan to waive the copayment for Inpatient hospital care. You say that you should not have a 
copayment and that you have been in the hospital before and there was not a copayment. The Plan denied your 
request. The Plan says the copayment applied was 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 $325 
copayment each day for days 1 - 5 each time you are admitted for Medicare-covered hospital care for Inpatient 
hospital care. As you had a 5-day inpatient stay the total allowed amount of the cost share is $1,625. Your out-
of-pocket maximum hadnt been reached, therefor the amount owed is $1,598.87. 
 
You have been asked to pay a $325 copayment each day for days 1 - 5 each time you are admitted for 
Medicare-covered hospital care for Inpatient hospital care. Inpatient hospital care falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for Inpatient hospital care on 
September 30, 2021 to October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from 
November 23, 2021, to November 24, 2021. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you should have met your 
maximum out-of-pocket (MOOP). The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for therapeutic radiology services, including radiation therapy.  The Plan contract says that enrollees must pay a maximum out-of-pocket of $4,500 per calendar year. 
 
The record shows you had not met your MOOP at the time the radiation therapy services were rendered. The 
Plan confirmed other claims were reprocessed and that affected your MOOP amount that you had seen 
reflected on your November 2021 statement. You have been asked to pay a total of $228.62, which is 20% 
coinsurance for radiation therapy from November 23, 2021, to November 24, 2021. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
November 23, 2021 G6015 $290.19 $72.55 
November 23, 2021 G6002 $58.86 $14.72 
November 23, 2021 77427 $153.37 $38.34 
November 23, 2021 77336 $62.95 $15.74 
Total  $141.35 
November 24, 2021 G6015 $290.19 $72.55 
November 24, 2021 G6002 $58.86 $14.72 
Total  $87.27 
  
Final Total $228.62 
  
Radiation therapy 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 radiation therapy provided from November 23, 
2021, to November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 3, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions 
are not covered. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy services provided on December 1, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Psychotherapy services provided on December 1, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic respiratory failure 
due to OHS and will now require frequent duration of non-invasive mechanical ventilation. The Plan denied 
your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was admitted with acute 
pulmonary edema and was diagnosed with obesity hypoventilation syndrome. The initial ABG showed mild 
CO2 increase with normal pH. The enrollee does not have a diagnosis for which Medicare covers a ventilator. 
The enrollee may benefit from home bipap during sleep.  Polysomnography with capnography and bipap 
titration are needed as an outpatient once he is stable. If needed, ASV or AVAPS can be provided via bipap. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership purchased on December 22, 
2021. 
 
You asked the Plan to pay for the health club membership. You say that you should be reimbursed for this gym 
membership with your benefit. The Plan denied your request. The Plan says you have already been reimbursed 
the full $100 health and wellness allowance for the 2021 Plan year. A two-year gym contract can only be 
reimbursed once in a two-year period and must be reimbursed in the year the membership was paid. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $100 for 
gym membership benefits per calendar year. Services are reimbursed for the year in which they were 
purchased. 
 
The Plans rules for coverage of gym benefits have not been met because the documentation shows that this 
membership was purchased on December 22, 2021, and you have already received the full $100 reimbursement 
allowance from the Plan for 2021. Therefore, we decided that the Plan does not have to pay for the health club 
membership purchased on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip replacement surgery, PT services 
and OT services provided from November 17, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayment for the hip replacement surgery, PT services and OT services. You 
say that you had your left hip done last year and it was fully covered by Medicare. The Plan denied your 
request. The Plan says the copayments applied correctly. The Plan says the claim reprocessed to only apply a 
$295 copayment for the hip replacement and a $30 copayment for each outpatient therapy 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 $295 
copayment for outpatient surgery services at an in-network outpatient hospital. The Plan contract also says that 
enrollees must pay a $30 copayment for physical and occupational therapy at an in-network outpatient hospital.  
 
You have been asked to pay a total of $355 ($295 copayment for the hip replacement surgery, a $30 copayment 
for PT services and a $30 copayment for OT services). The hip replacement surgery falls within the 
Outpatient hospital services benefit category. The PT services and OT services fall 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 the hip 
replacement surgery, PT services and OT services provided from November 17, 2021, to November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on December 
10, 2021. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that you had the services done 
at an in-network location. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
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 $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. Please note 
that the in or out of network location does not affect the amount applied to the deductible.  
 
 This cost sharing is a contractual obligation that had not been met at the time the laboratory services were 
received on December 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 21, 2022 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 11, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 
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 procedure code 70450 billed for date of service August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on December 1, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit for D0150 has already been exhausted. 
 
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. The Plan covers a 
comprehensive oral evaluation once every three years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on August 21, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay 
for a comprehensive oral evaluation (D0150) provided by a participating provider on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
March 17, 2021. 
 
You asked the Plan to pay for a crown. You say that you were not supposed to have a maximum allowance 
amount. The Plan denied your request. The Plan says the maximum benefit allowance amount has already been 
exhausted. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided by an out-of-network provider on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says the criteria for admission to an SNF are not met. The record shows that the enrollee has 
had limited progress toward meeting their goals and has declined to try to walk since admission. 
 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 the enrollee has stabilized medically and is 
ready for discharge from the hospital. He does not require skilled nursing and/or skilled therapy services on a 
daily basis. The enrollee is medically stable and can receive further rehab services in a lower level of care.  
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parenteral medication, complex wound care or nutrition given by feeding tube. He is 
medically stable without any acute exacerbations of chronic medical problems. The enrollee has declined to 
ambulate with skilled rehab services and would not benefit from daily rehab in an inpatient setting. Admission 
to a SNF for inpatient skilled rehab services is not medically necessary. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you contacted the plan and were told prior 
authorization was not needed. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided on July 26, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 27, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services should be paid by the Plan. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on October 27, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 30, 2021, to October 4, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like to file 
an appeal for the copayment amount. The Plan denied your request. The Plan says the proper copayment was 
applied for the service that was rendered. 
 
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 for each day for days 1 - 5 each time you are admitted for Medicare-covered hospital care with the 
day before you are discharged is your last inpatient day. With the date of service starting on September 30, 
2021, and the date of discharge being October 4, 2021, there was 4 days chargeable towards the inpatient 
hospital stay. The total copayment amount for the 4 days was $1,300 ($325 copayment per day x 4 days). 
 
  You have been asked to pay a $1,300 copayment for an inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided from September 30, 2021, to October 4, 2021.