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

 
We decided that the Plan has to pay for the laboratory services provided on September 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has provided insufficient evidence to support their 
reasoning for the denial of payment for the laboratory services. The Plan denies payment due to a 
missing/incomplete/invalid taxpayer identification number (TIN); however, the Plan provides no supporting 
documentation that the TIN is incorrect based on Medicare criteria. Therefore, we decided that the Plan has to 
pay for the laboratory services provided on September 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency diagnostic exam (D0140) provided on 
September 23, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that you would not have used the dental service if 
you had known they were out of network. You also say that you cannot pay this bill. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and emergency diagnostic exam is 
listed as covered, you pay 100% for this service when received out of network. Therefore, we decided that the Plan does not have to pay for the emergency diagnostic exam (D0140) provided on September 23, 2021, by the 
out of network dentist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transvaginal ultrasound (76830) rendered by the out-of-
network (OON) provider on October 20, 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 transvaginal ultrasound (76830) rendered by the out-of-network (OON) provider 
on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology services (62323) 
provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic radiology services. You say that the services 
should be covered as you disagree with the charges. 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 $250 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $250 copayment for the diagnostic radiology services. Diagnostic 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 diagnostic radiology services (62323) provided on January 
3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be completed at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous and you should be able to be safely treated at a lower level of care when treatment has 
completed. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-
network (OON) provider on November 17, 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 laboratory service (88305) rendered by the out-of-network (OON) provider on 
November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from February 22, 2021, through 
October 21, by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that there is a discrepancy between providers in the 
facility who have opted out of Medicare. The Plan denied your request. The Plan says payment cannot be made 
to a provider opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. We have confirmed through the Centers for Medicare and Medicaid 
services was opted out of Medicare at the time of the services in question. Therefore, we decided that the Plan 
does not have to pay for the dental services provided from February 22, 2021, through October 21, by a 
provider who has opted out of Medicare.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided by a network facility from September 1, 2021, to September 18, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that this claim was a new admission, and 
you pay a $0 copayment for days 1 to 20. 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 $0 
copayment for each day for days 1 to 20 and a $184 copayment each day for days 21 to 57.   
You have been asked to pay a $2,024 copayment for the SNF stay. The SNF stay falls within the Skilled 
Nursing Facility (SNF) care benefit category. The record shows the benefit period did not end as there was not 
a 60-day gap between August 12  25, 2021, to August 31, 2021, and September 1 -18, 2021. See chart below. 
 
Dates of Service Service SNF Days Copayment Day Count Member Liability 
August 12, 2021, to 
August 25, 2021 
SNF stay 1-13 $0 13 $0 
August 31, 2021 SNF stay 14 $0 1 $0 
September 1, 2021, to 
September 6, 2021 
SNF stay 15-20 $0 5 $0 
September 7, 2021, to 
September 18, 2021 
SNF stay 21-32 $184 11 $2,2024 
Total     $2,2024 
 
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 skilled nursing facility (SNF) stay provided by a 
network facility from September 1, 2021, to September 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital visit provided from 
August 2, 2021, to August 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. 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 $200 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $800 copayment for 4 days of inpatient hospital care ($200 x 4 = $800). 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 visit provided from August 2, 2021, to 
August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on October 29, 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 (99215) rendered by the out-of-network (OON) provider on  
October 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
emergency transport (A0429) provided on July 25, 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 $250 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
 
 You have been asked to pay a $250 copayment for the Medicare-covered one-way ground ambulance trip 
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 ambulance service, basic life support, 
emergency transport (A0429) provided on July 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cataract surgery (66984) performed on 
December 9, 2021. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies 
to Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers. This cost sharing is a contractual obligation that had not been met at the time the cataract surgery was 
received on December 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
cataract surgery (66984) performed on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Durable Medical Equipment, Outpatient 
Diagnostic/Rehabilitation, and Physician Services (99214, 73562, E0143, 97110) provided from January 26, 
2021, to May 28, 2021. 
 
You asked the Plan to waive the cost-sharing for the Durable Medical Equipment, Outpatient 
Diagnostic/Rehabilitation, and Physician Services. You say that the services should be covered as you disagree 
with the charges. 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 Durable medical equipment (DME) and related supplies, a $30 copayment for Outpatient 
diagnostic tests and therapeutic services and supplies, a $25 copayment for Outpatient rehabilitation services, 
and a $40 copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to the following cost-sharing: 
 
Date of 
Service 
Procedure 
code 
Billed 
amount 
Approved 
amount 
Plans share Your 
share 
1/26/2021 99214 $140.00 $127.03 $87.03 $40.00 
1/26/2021 E0143 
$270.00 
$31.43 $25.14 $6.29 
1/26/2021 L1812 
$120.00 
$78.15 $62.52 $15.63 
3/26/2021 73562 $85.00 $39.01 $9.01 $30.00 
4/12/2021 97161 
$110.00 
$98.86 $73.86 $25.00 
4/15/2021 97110 
$48.00 
$29.43 $4.43 $25.00 
4/20/2021 97110 
$48.00 
$29.43 $4.43 $25.00 
4/22/2021 97140 $50.00 $21.16 $0.00 $21.16 
4/22/2021 97110 
$48.00 
$29.43 $25.59 $3.84 
4/27/2021 97140 
$50.00 
$21.16 $0.00 $21.16 
4/27/2021 97110 $48.00 $29.43 $25.59 $3.84 
4/29/2021 97110 $48.00 $29.43 $4.43 $25.00 
5/28/2021 73562 
$85.00 
$39.01 $9.01 $30.00 
               Total Responsibility: $246.92 
 
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-sharing for Durable Medical Equipment, Outpatient 
Diagnostic/Rehabilitation, and Physician Services (99214, 73562, E0143, 97110, 97140) provided from 
January 26, 2021, to May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (K0553) provided on 
October 23, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says required documentation 
for payment is missing. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (K0553) provided on October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided on November 
13, 2021. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you have never paid a 
coinsurance before, and you do not agree with this bill. The Plan denied your request. The Plan says 
coinsurance 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 20% 
coinsurance for genetic testing.  
 
  You have been asked to pay $362.03, which is 20% of the allowed amount for the laboratory services. The 
allowed amount is $1,810.15 (20% x $1,810.15 = $362.03). Laboratory services fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for laboratory services provided on November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on January 14, 
2022. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you went to get your nails 
trimmed and never even saw the doctor. 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 $30 
copayment for each in-network Medicare-covered podiatry service.  
 
You have been asked to pay $30 for podiatry services. Podiatry services fall within the Podiatry 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 podiatry services provided on 
January 14, 2022.