Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter placement of intracoronary 
stent(s), with coronary angioplasty when performed; single major coronary artery or branch (92928) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve percutaneous transcatheter placement of intracoronary stent(s), with 
coronary angioplasty when performed; single major coronary artery or branch to be provided by an OON 
provider. You say that the in-network providers provided in the denial letter cannot complete the procedure and 
they do not have the tools. The Plan denied your request. The Plan says all care with the exception of emergent 
or preauthorized care must be provided by the Plan's network of contracted providers. 
 
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 
percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; 
single major coronary artery or branch (92928) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided by an OON 
provider on July 14, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment was medically 
necessary. 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 subsequent nursing facility care provided by an 
OON provider on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on January 10, 2022, to 
January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and it is 
the responsibility of the nursing facility to obtain authorization. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on January 10, 2022, to January 
20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are filing an appeal to review the denial of the 
services. 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 an office visit provided on January 24, 2022 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93000) provided on December 
29, 2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the ECG. You say that you would like this claim to be reprocessed. The Plan 
denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says 
that there was no prior authorization, and the referring provider is a non-contracted 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 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 electrocardiogram (ECG) (93000) provided on 
December 29, 2021 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 emergency telehealth services provided on 
January 1, 2022. 
 
You asked the Plan to waive the copayment for the emergency telehealth services. You say that you only called 
to make an appointment for COVID-19 treatment. 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 $40 
copayment for specialist telehealth services.  
 
The record shows that history, evaluation, treatment planning, and education were provided during the 
telehealth visit. Therefore, you have been asked to pay a $40 copayment for the emergency telehealth services. 
The emergency telehealth services fall 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 emergency telehealth services 
provided on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on March 13, 
2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you don't feel that they 
helped you so you shouldn't have to pay. 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 traditional urgent care clinic.  
 
You have been asked to pay $45 copayment for urgent care services. Urgent care services fall within the 
Urgently needed 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 urgent care 
services provided on March 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
October 8, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be covered 
since this was a continuous sickness that continued after discharge. 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 $325 
copayment per days 1 through 5 of your Medicare covered hospital stay.  
 
 
 
 You have been asked to pay $1,625 ($325 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 copayment 
for inpatient hospital stay provided from October 8, 2021, to October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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. The Plan also says that they have 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 an office visit provided on March 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2022, 
to February 16, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 The file shows that the enrollee received 100 days of SNF care during the benefit period from July 6, 2021, to 
January 17, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from January 18, 2022, to February 
16, 2022.
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 sending the enrollee to a nursing home facility is not 
acceptable as they will not be able to provide the 24-hour care and multiple dialysis treatments that can be 
performed in the hospital. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for approval of IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee may 
benefit from continued physical and occupational therapy, their rehabilitation needs can be safely provided in a 
lower intensity and alternate 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 pay for an office visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have been to the clinic prior, and this was a 
follow up visit. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no referral from an in-network provider or an approved authorization. The Plan also says claims paid 
prior to April 3, 2020, were paid under the Emergency Disaster Waivers Exceptions. 
 
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 an office visit provided on February 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips. The Plan denied your request. The Plan says once you have used 60 one-way trips, your 
benefit will be exhausted, and no additional trips can be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two bifocal spherocylinder lenses (V2204 x2) provided 
on April 5, 2022. 
 You asked the Plan to pay for the bifocal spherocylinder lenses. You say that you do not understand how this 
benefit can be exhausted when you have not used it in five years. The Plan denied your request. The Plan says 
your benefit has been exhausted. 
 
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 up to a $150 allowance per calendar year toward the purchase of eyeglasses or 
contact lenses. 
 
We looked at the file and the Plan's rules. The record shows that your $150 eyeglasses benefit was exhausted 
on the frames. Based on this information, we decided that the Plan's rules for coverage of the bifocal 
spherocylinder lenses have not been met. Therefore, we decided that the Plan does not have to pay for the two 
bifocal spherocylinder lenses (V2204 x2) provided on April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
November 3, 2021, to November 13, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that since this was the same 
symptoms that she had before it should be covered. 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 $325 
copayment per day for days 1 through 5 of your Medicare covered hospital stay.  
 
 
 You have been asked to pay $1,625 ($325 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 copayment 
for inpatient hospital stay provided from November 3, 2021, to November 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair provided on February 21, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for transport chair. You say that you did not think there would be a problem with 
this because you are sick and needed this item. The Plan denied your request. The Plan says the denial of 
payment for this item is correct, because this provider is out-of-network with the Plan and this item can be 
obtained from an in-network supplier. 
 
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 transport chair provided on February 21, 2022 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that this should be covered in full because 
under the Vision care category in your Evidence of Coverage there is no mention of coinsurance. The Plan 
denied your request. The Plan says the coinsurance 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 20% 
coinsurance for all other Medicare Part B drugs. 
 
You have been asked to pay $366.30 which is 20% of the allowed amount for the injection. The allowed 
amount is $1,831.49 (20% x $1,831.49= $366.30). Injections fall 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 coinsurance for injection provided on March 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are coverable and this claim should 
be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services 
provided on October 30, 2021.