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

We decided that the Plan does not have to waive the cost sharing for the outpatient surgery you had on March 31, 2021.

You asked the Plan to waive the cost sharing for the outpatient surgery. You say that you had this surgery because the doctor left a piece of catheter in your arm during a previous surgery. You stated that you should not be forced to pay twice because of the doctor's error. The Plan denied your request. The Plan says you were charged this cost sharing 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 $1000 deductible for outpatient surgery. Once this deductible is met, you have a copayment of $350 for outpatient surgery. 

You have been asked to pay a $1000 deductible and a $350 copayment for the outpatient surgery. This cost sharing applies regardless of the reason for the procedure. 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 the outpatient surgery you had on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair. 
 
You asked the Plan to pre-approve a commode chair. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a commode chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 20, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft (D4263) and guided tissue 
regeneration (D4266). 
 
You asked the Plan to pre-approve the bone replacement graft (D4263) and guided tissue regeneration 
(D4266). You say that these teeth are exhibiting advanced periodontal disease and have a poor prognosis if 
treated. You say that the patient needs bone replacement and guided tissue regeneration in order to support the 
function of the bridge. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 15, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the benefit of a $250 allowance was applied to the purchase, and the member has a responsibility of $48 which was paid at the time of purchase.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows the Plan benefit of a $250 allowance was applied to
the purchase. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses
provided on June 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for congestive heart failure. The enrollee medical problems are stable. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. The enrollee's care needs can be 
met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam you had on May 14, 
2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you didn't need a specialist 
visit, just an eye exam and glasses. You stated that you shouldn't pay this copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 $40 
copayment for exams to diagnose and treat diseases or conditions of the eye.  
 
You have been asked to pay a $40 copayment for the medical eye exam. The medical records from this visit 
confirm that you had a comprehensive medical eye exam.  You were evaluated for your diabetes, your 
intraocular lens was evaluated, and you were evaluated for myopia as well. These are medical conditions that 
are beyond the scope of a routine eye exam. That is why the medical eye exam falls within the exams to 
diagnose and treat diseases or conditions of the eye 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 medical eye exam you had on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 6, 2021, 
through May 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. 
 
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 that the patient is a 58-year-old female who presented to the hospital after being 
assaulted. She was found to be positive for methamphetamines, marijuana, and benzodiazepines. Her agitation 
and high blood pressure were treated in the emergency department. Basic workup did not reveal anything acute 
besides bruising on eye, poor nutrition, and agitation, which was responding to initial treatment. There were no 
plans for inpatient behavioral health treatment. Based on the documentation provided, they were not expected 
to require hospital services that would likely cross 2 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 from May 6, 2021, through 
May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (64555) and implantable neurostimulator, pulse generator, any type (L8679). 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that it was determined by the 
provider that the enrollee would be an excellent candidate for the percutaneous electrical nerve stimulation (PENS) unit to help with chronic pain and reduce the use of narcotics. The Plan denied your request. The Plan 
says this device is not covered by Medicare or the health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an implantable neurostimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array (64555) and implantable 
neurostimulator, pulse generator, any type (L8679).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services can be provided 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81120, 81121, 81173, 81201, 81210, 81235, 
81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81404, 
81405, 81406) provided February 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 
81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported 
in the medical record. Specifically, the services were billed using unbundled codes. There is a more appropriate 
CPT code to describe the services billed (81479).  Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 

Therefore, we decided that the Plan does not have to pay for lab services (81120, 81121, 81173, 81201, 81210, 
81235, 81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 
81404, 81405, 81406) provided February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services provided from 
October 26, 2020, and October 30, 2020. 
 
You asked the Plan to waive the copayments for the chiropractic services. You say that the Plan was waiving 
cost shares, so these copayments should be removed. The Plan denied your request. The Plan says the 
copayment waiver program was only in effect from May 11, 2020, to September 30, 2020.  These services 
occurred after the waiver program ended, so these copayments were charged correctly. The Plan says that these 
claims were paid at the in-network rate. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $20 copayment per visit for chiropractic services.  
 The enrollee has been asked to pay a $20 copayment per visit for the chiropractic services. 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 copayments for chiropractic services provided from October 26, 2020, and October 
30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient injection procedure you had at an outpatient hospital facility and the Boniva you received on May 1, 2021.
You asked the Plan to waive the cost sharing for the outpatient injection procedure and the Boniva. You say that you do not believe this injection should be considered a surgical service. The Plan denied your request. The Plan says you were charged this cost sharing 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 $240 copayment for outpatient hospital services and 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $240 copayment for the outpatient injection procedure and 20% coinsurance for
the Boniva. The outpatient injection procedure falls within the outpatient hospital services benefit category. The Boniva falls within the Medicare Part B drugs 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 sharing for the outpatient injection procedure you had at an outpatient hospital facility and the Boniva you received on May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital visits provided from 
August 16, 2019, to June 9, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient hospital visits. You say that you met the MOOP 
amount and should not be responsible for the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 the combined MOOP 
amount for 2019 and 2021 is $10,000. Your contract with the Plan also clearly says that you must pay 50% 
coinsurance for out-of-network outpatient hospital services. 
 
You received outpatient hospital visits from an out-of-network provider from August 16, 2019, to June 9, 2021. According the evidence of benefits provided in the case file, you had not met the MOOP amount for 2019 prior 
to receiving the services. The record shows that you had met the MOOP amount for 2021 with the processing 
of the claims in question. Therefore, you are responsible to pay your share of the costs-sharing charges. Please 
see the chart below.  
 
Date of Service Service Allowed Amount Amount You Owe 
8/16/2019 Outpatient Hospital Visit  $1,866.78 $933.39 
8/19/2019 Outpatient Hospital Visit  $384.79 $192.39 
9/4/2019 Outpatient Hospital Visit  $271.36 $135.68 
3/2/2021 Outpatient Hospital Visit  $143.45 $71.72 
5/25/2021 Outpatient Hospital Visit  $472.63 $175 
6/4/2021 Outpatient Hospital Visit  $23,370.12 $6,676.84 
6/8/2021 Outpatient Hospital Visit  $143.45 $71.72 
6/9/2021 Outpatient Hospital Visit  $143.45 $71.72 
 
The total amount you owe for all of the dates of service above is: $8,328.46.  
 
You have been asked to pay the total amount of $8,328.46 for outpatient hospital visits. Outpatient hospital 
visits fall 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 
coinsurance for outpatient hospital visits provided from August 16, 2019, to June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder, saddle bag, and transit system (each coded 
K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve a cup holder, saddle bag, and transit system. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
primarily convenience items. Therefore, we decided that the Plan does not have to pre-approve a cup holder, 
saddle bag, and transit system (each coded K0108) for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy and does not have to waive 
the copayment for a CT scan provided from February 10, 2021, to March 24, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy and to waive the copayment for a CT scan. You 
say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $150 copayment for radiological diagnostic services.  
 
You received Chemotherapy and a CT scan from February 10, 2021, to March 24, 2021. Therefore, you are 
responsible to pay your share of the cost-sharing charges. Please see the chart below.  
 
Date of Service Service Allowed Amount Amount You Owe 
2/10/2021 Chemotherapy  $294.70 $58.94 
2/10/2021 Chemotherapy $7,406.00 $1,481.20 
3/3/2021 Chemotherapy  $294.70 $58.94 
3/3/2021 Chemotherapy $7,406.00 $1,481.20 
3/20/2021 CT scan $412.65 $150 
3/24/2021 Chemotherapy $294.70 $58.94 
3/24/2021 Chemotherapy $7,406.00 $1,470.78 
 
The total amount you owe is: $4,760.  
 
You have been asked to pay the total amount of $4,760 for chemotherapy and a CT scan. Chemotherapy falls 
within the Medicare Part B prescription drugs benefit category. A CT scan falls within the outpatient diagnostic 
tests and therapeutic service 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 chemotherapy and does not have to waive the copayment for a CT scan provided from February 10, 2021, 
to March 24, 2021.