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

 
We decided that the Plan does not have to pay for the travel and lodging services provided from January 19, 
2022, to January 20, 2022. You asked the Plan to pay for the services provided. You say that you had to travel for a follow-up visit with 
your plastic surgeon. The Plan denied your request. The Plan says the services are not related to a transplant. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan covers worldwide emergency and urgent care services outside of the United States under 
certain circumstances. 
 
We looked at the file, and Medicare rules. The file shows that you received care outside of the United States. 
The services were not urgent or emergent. The travel and lodging services were not related to transplant 
services. Based on this information, we decided that the rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the travel and lodging services provided from 
January 19, 2022, to January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT provided on January 26, 2022. 
 
You asked the Plan to waive the copayment for a CT. You say that this scan was ordered by your primary care 
physician as part of your annual wellness visit. You say it was your understanding that this would be covered 
as part of the preventive exam. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $175 
copayment for Medicare-covered diagnostic radiology services; $125 to $175 copayment ($125 at free standing 
Radiology Clinic; $175 at outpatient hospital).  
 
 
 
 
 You have been asked to pay $113.36, which is less than the $175 copayment. The CT 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 a CT provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on December 20, 
2021. 
 
You asked the Plan to pay for the billed services. You say that detailed information supports medical necessity. 
The Plan denied your request. The Plan says the documentation did not include a valid proof of delivery. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. The packing slip and proof of delivery provided are for a 
different date of service than the one at issue. 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 provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 10, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you would like your money back for 
your services. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 a $35 
copayment for each in-person specialist visit. Covered services include: Consultation, diagnosis, and treatment 
by a specialist.  
 
You have been asked to pay a $35 copayment for office visit. Office visit falls within the Physician/Practitioner 
services, including doctor's 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 office visit on February 10, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on April 22, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice at 
the time the services were rendered. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on April 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency room services (ER) on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for Emergency room services (ER). You say that you are unable to 
pay this invoice as it would be a financial burden for you. The Plan denied your request. The Plan says the cost-
sharing you are being charged 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 a $50 
copayment for emergency care worldwide. Emergency care refers to services that are: Furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $50 copayment for Emergency room services (ER). Emergency room services 
(ER) falls within the Emergency 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 
Emergency room services (ER) on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on October 6, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the surgical assistant does not accept assignment or bill Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records support the services. The Plan 
denied your request. The Plan says the panel did not meet Medicare coverage criteria. 
 
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.  
 
 
 We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. The records do not show that the 
testing was ordered by the enrollees treating physician for a specific medical problem. This testing is not 
covered by Medicare for screening purposes. 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 provided on October 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs are non-skilled in nature. 
 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 
SNF services are not medically reasonable and necessary. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing 
or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for SNF services. 
 
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 for the enrollee.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that on review of the available records the enrollee with debility is medically stable.  
 The enrollee does not need physical medicine and rehabilitation physician supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical 
therapy and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower 
intensity setting such as in a skilled nursing facility.  
 
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 deductible for a back injection procedure performed on 
February 2, 2022. 
 
You asked the Plan to waive the deductible for the injection. You say that you were not aware of the 
deductible. 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 $750 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 Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the injection was received on February 2, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for a back injection procedure performed on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on January 
25, 2022. 
 You asked the Plan to waive the copayment for the eye exam. You say that this service was for the enrollee's 
complete eye exam. You also say that there should be no copay. The Plan denied your request. The Plan says 
this claim was processed correctly with the copay of $40.00. The Plan also says that this exam was for a 
medical diagnosis and not a preventive service. 
 
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. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that this was a medical exam which 
resulted in a medical diagnosis. You are responsible for a $40 copay for each Medicare-covered eye exam to 
diagnose and treat diseases and conditions of the eye. Based on this information, we decided that the Plan's 
rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to 
waive the copayment for the eye exam (92014) provided on January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on November 16, 2021. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not a covered benefit while under an outpatient hospital stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on November 16, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on 
January 26, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on 
January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was a follow up visit 
from a surgery, and you shouldn't have a copayment for that. The Plan denied your request. The Plan says the 
copayment applied 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall 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 specialist office visit provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that the enrollee has been with this provider for 
three years to monitor their diabetes. The Plan denied your request. The Plan says unauthorized, non-plan care 
is not covered. 
 
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 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 February 1, 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 copayment for a specialist office visit and Aminolevulinic 
acid hcl provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit and Aminolevulinic acid hcl. You say 
that you do not think you should pay $40 for a specialist if you did not see them. You also say you did not see a 
physician; you saw a nurse. The Plan denied your request. The Plan says you were 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 $40 
copayment for each Medicare-covered visit to a specialist. Your contract with the Plan also clearly says that 
you must pay 20% of the total cost for all Medicare Part B drugs other than a 30-day supply of insulin. 
 
 You have been asked to pay a $40 copayment for a specialist office visit. You have also been asked to pay 
$77.68 in coinsurance, which is 20% of the allowed amount for Aminolevulinic acid hcl ($388.42 allowed 
amount x 20% coinsurance = $77.68). Aminolevulinic acid hcl falls within the Medicare Part B prescription 
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 copayment for a specialist office visit and 
Aminolevulinic acid hcl provided on January 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0002) provided on December 13, 
2021. 
 
You asked the Plan to pay for the coronavirus test. You say that this should be covered. You say that the test 
was required by law for travel to another country. The Plan denied your request. The Plan says the coronavirus 
testing was not urgent. The Plan says that the testing as required by a governmental body in order to travel is 
not necessary to treat an illness. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by the foreign government for the purposes 
of routine travel. Based on this information, we decided that Medicare rules for coverage of screening testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus test (U0002) 
provided on December 13, 2021.