Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided 
on March 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that the facility you received these glasses from is listed as 
an in-network provider under your plan. The Plan denied your request. The Plan says this pair of glasses was 
provided by a provider who is not in the Plan's network. 
 
 
 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. The Plan covers these services when they are rendered by a network optical provider. 
 
We looked at the file and the Plan's rules. The record shows that you received these glasses from an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of the glasses have 
not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and progressive 
lenses (V2781) provided on March 26, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network cataract surgery provided 
on June 8, 2022, and June 15, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network cataract surgery. You say that you were 
unaware of how much this would cost and need it overturned. You only got the basic surgery. The Plan denied 
your request. The Plan says the coinsurance that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for out-of-network surgery services. The allowed total amount of these procedures was $2,052.48, 
resulting in a total coinsurance of $1026.24 ($2,052.48 x 50% = $1026.24). 
 
You have been asked to pay a $1026.24 coinsurance for out-of-network cataract surgery. Out-of-network 
cataract surgery falls within the Out-Of-Network Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 out-of-network cataract surgery provided on 
June 8, 2022, and June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the electric stimulation therapy (97014) 
provided on May 11, 2022. 
 
You asked the Plan to issue reimbursement 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 this service is not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to issue reimbursement for the electric stimulation therapy (97014) provided on May 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for lab work provided on February 23, 2022. 
 
You asked the Plan to waive the cost share for lab work. You say that these labs are supposed to be covered for 
patients with rheumatoid arthritis/ The Plan denied your request. The Plan says the cost share was applied 
correctly. You had a remainder left on your deductible, and the cost was applied to that. There was also a 
coinsurance initiated after the deductible was met. 
 
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 
deductible and 20% coinsurance for lab work. The allowed amount was $989.00. You are responsible for a 
deductible amount of $205.46 and a coinsurance amount of $57.81 for this service ($205.46 + $57.81 = 
$263.27). 
 
You have been asked to pay $263.27 cost share for lab work. Lab work 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 cost share for lab work provided on February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network (OON) inpatient care 
provided from March 15, 2022, to March 17, 2022. 
 
You asked the Plan to waive the coinsurance for the OON inpatient care. You say that you feel the care should 
be considered in-network due to the necessity. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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% 
coinsurance for each inpatient stay at an out-of-network facility.  
 
The file shows that the Plan verified the facility is not a network facility. Therefore, you have been asked to 
pay $4,046.92, which is 30% of the allowed amount for the OON inpatient care ($13,489.72 allowed amount x 
30% coinsurance = $4,046.92). The OON inpatient care falls within the Inpatient Hospital Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for out-of-network (OON) inpatient care provided 
from March 15, 2022, to March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay proved from February 7, 
2021, to February 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you cannot afford this 
copayment on your own as it is too costly. The Plan denied your request. The Plan says the copayment that was 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day, for days 1 to 6 for inpatient mental health care.  
 
You have been asked to pay a $1,650 copayment for an inpatient stay ($275 x 6 = $1650). An inpatient stay 
falls within the Inpatient Mental Health Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient stay proved from February 7, 2021, to February 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of vertebrogenic low back pain has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the occupational therapy services provided 
on April 7, 2022. 
 
You asked the Plan to waive the deductible for the occupational therapy services. You say that you were 
misinformed of what the session was going to consist of, and the services provided were not beneficial to you. 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient Rehabilitation Services. 
At the time this claim was processed, $0 of the $750 deductible had been met. The allowed amount of this 
claim is $119.16, resulting in a deductible amount of $119.16.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible which applies to Outpatient Rehabilitation Services. This cost sharing is a contractual 
obligation that had not been met at the time the occupational therapy services was received on April 7, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the occupational therapy services 
provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the office visit (99204) provided on 
May 2, 2022. 
 
You asked the Plan to pay an additional amount for the physician service. You say that this service was 
requested by the Veteran's Administration. You say that that this should have been paid by them. You also say 
that you received a bill from your plan. The Plan denied your request. The Plan says the claim processed 
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 $50 
copayment for Physician/Practitioner Services.  
 
You have been asked to pay a $50 copayment for the physician service. The physician service falls within the 
Physician/Practitioner 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 pay an additional amount 
for the office visit (99204) provided on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is a non-participating provider. The Plan also says that 
the referring provider involved in these services is a non-participating provider with the Plan. The Plan also 
says they did not authorize any services for this 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 laboratory services provided on July 15, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) with 
associated sleeve (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that this equipment 
is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage of the requested intermittent limb compression equipment have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) with associated sleeve (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies provided on 
April 29, 2022, by an OON provider. 
 
You asked the Plan to pay for limited bilateral noninvasive physiologic studies. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 limited bilateral noninvasive physiologic studies 
provided on April 29, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 22, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are appealing the coinsurance 
assessed on the injection. The Plan denied your request. The Plan says you have been charged the correct 
coinsurance 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 20% 
coinsurance for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $275.40, which is 20% of the allowed amount for the injection. The allowed 
amount is $1,377.00 (20% x 1,377.00 = $275.40). The injection falls within the Medicare Part B chemotherapy 
drugs and other 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 coinsurance for an injection provided on April 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 
27, 2022, to January 31, 2022. 
 
You asked the Plan to pay for the SNF services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 26, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) services provided from January 27, 2022, to January 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment received by the 
member was medically necessary. The Plan denied your request. The Plan says there is no referral from an in-
network physician. The Plan also says that there are in-network physicians available. 
 
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 subsequent nursing facility care provided on May 
10, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 16, 2022, by OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration for the 
services provided. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 
 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 laboratory services provided on March 16, 2022, 
by an OON provider.