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

 
We decided that the Plan has to pay for the insertion of intrauterine device (IUD) provided on September 8, 
2021. 
 
You asked the Plan to pay for the IUD insertion. You say that you would like this claim reprocessed for 
payment. The Plan denied your request. The Plan says that the claim has denied correctly based on not meeting 
Medicare LCA coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the IUD insertion. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that you are a 68-year-old woman who was diagnosed with benign endometrial hyperplasia. 
The enrollee previously had gastric bypass surgery. Treatment options, including oral progesterone and an 
IUD, were discussed with the enrollee. You did not feel that she would be able to take a pill daily, and elected 
to proceed with the IUD. In this case, LCA A58649: IUD (Hormone-Eluting) for Endometrial Hyperplasia, 
states that it has been determined that the use of a progestin-containing IUD may be approved for use in an 
enrollee who presents with endometrial hyperplasia without atypia. The Plan's denial is based on language 
found in LCA A55951 which is not valid for the enrollee's state in this case. Based on the correct LCA, 
payment can be made for this service. 
 
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 IUD insertion have been met. Therefore, we decided that the Plan has to pay 
for the insertion of intrauterine device (IUD) provided on September 8, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you were unaware you 
had a copayment for telehealth services. 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 a $30 
copayment for an in-network specialist telemedicine visit.  
 
You have been asked to pay a $30 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits 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 specialist telehealth visit provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and a brief emotional/behavioral assessment 
provided on January 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit and a brief emotional/behavioral assessment. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they 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 a home visit and a brief emotional/behavioral 
assessment provided on January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for radiation therapy services and MRI provided 
from October 6, 2021, through October 18, 2021. 
 
You asked the Plan to waive the coinsurance and copayment for radiology services and diagnostic radiology 
service. You say that prior to receiving treatment, you were told this was covered in full. You say you cannot 
afford this additional cost. The Plan denied your request. The Plan says the coinsurance and copayment are 
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 20% 
coinsurance for Medicare-covered radiology therapy services and $75 copayment for Medicare-covered MRI.   
You have been asked to pay $1,509.50, for the radiation therapy and MRI. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 6, 2021- 
October 18, 2021 
Radiation Therapy $7,172.56 20% $1,434.50 
October 6, 2021 MRI $79.84 $75 $75 
TOTAL:    $1,509.50, 
 
The radiation therapy services, and MRI 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 cost share for the radiation therapy 
services and MRI provided October 6, 2021, through October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit on December 6, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you were advised this visit should 
be fully covered. The Plan denied your request. The Plan says the copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for each Medicare-covered in-network specialist visit.  
 
You have been asked to pay $10.92, which is less than the standard $35 copayment for specialist visit. The 
specialist visit falls within the Physician/Practitioner services, including doctors office visits 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 specialist visit on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided from October 
2, 2021, to October 28, 2021. 
 
You asked the Plan to waive the coinsurance for dialysis treatments. You say that you were in catastrophic 
phase at the time of service. You also say that under 2021 rules you should not be billed a copayment, and this 
was processed wrong. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. The Plan also says that dialysis treatment is not a Part D drug, and the catastrophic coverage 
stage does not apply. 
 
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 outpatient dialysis treatments.  
 The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $66.01, which is 20% coinsurance of the allowed amount for each dialysis treatment from October 2, 2021, 
to October 28, 2021 ($330.07 allowed amount x 20% coinsurance = $66.01). You have been asked to pay a 
total of $660.10 ($66.01 coinsurance x 10 treatments = $660.10). Dialysis treatments fall within the Services to 
Treat Kidney Disease 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 dialysis 
treatments provided from October 2, 2021, to October 28, 2021.  
 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the professionals working with the enrollee 
strongly disagree with the Plan's determination. You say that the enrollee has no plateaued and is still 
ascending to a place where she can return home safely. The Plan denied your request. The Plan says the 
enrollee is medically stable and does not require daily skilled services. The Plan says that the skilled service 
needs can safely be delivered on an intermittent basis.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an orthopedic specialist office visit 
provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you met your maximum 
out-of-pocket in September 2021 and are still being charged a $40 copayment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for a specialist office visit. The Plan contract also says that enrollees must pay a $4,900 maximum out-of-pocket per calendar year. 
 
The record shows a previous claim was reprocessed which made you fall below the $4,900 MOOP amount. 
Therefore, a cost sharing amount was applied to your specialist office visit on November 11, 2021. You have 
been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 an orthopedic specialist office visit provided on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient Hospital Care provided on April 16, 2021 to April 
25, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Inpatient Hospital Care. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says member does not have out of network benefits. 
 
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 Inpatient Hospital Care provided on April 16, 
2021 to April 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on medical necessity. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need coverage to stay in the rehab 
facility. The Plan denied your request. The Plan says continued SNF care after April 30, 2022, 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing needs.  You do not have documented skilled therapy needs.  Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your condition.  Your care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic interventions that focus on cognitive function 
provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic interventions that focus on cognitive function. You say that you 
would like reconsideration stating the provider referral is submitted. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan and the services were not referred by a network 
provider. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they 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 therapeutic interventions that focus on cognitive 
function provided on January 19, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 12, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not need medical 
attention and feel discriminated against. The Plan denied your request. The Plan says 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 $290 
in-network non-emergency copayment per date of service regardless of the number of trips for ambulance 
services.  
 
 
  You have only been asked to pay $170, which is less than the standard $290 copayment for ambulance 
services. Ambulance services fall within the ambulance 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 ambulance services provided on December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 4, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
August 4, 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 ophthalmological services provided on December 1, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that a provider performing services in a 
nursing home facility is not responsible to obtain authorization, and instead, their visit should fall under the 
authorization that the nursing home has for the stay of the patient. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan, and based on the documentation submitted, they have 
determined that the services rendered to the member are not urgent or emergent, nor were they approved in 
advance by a network provider. 
 
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 ophthalmological services provided on December 
1, 2021, by an out-of-network (OON) provider.