Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
3, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you only went in for a prescription 
refill. 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 $45 
copayment for physician specialist services.  
 
You have been asked to pay a $45 copayment for the office visit. The 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 a specialist office visit provided on March 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not understand why the 
procedure was not fully covered. 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 $75 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound 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 retroperitoneal ultrasound provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on January 26, 2022. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. 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 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$33.33, which is 50% of the allowed amount for the OON INR monitoring ($66.67 allowed amount x 50% 
coinsurance = $33.33). The OON INR monitoring 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 coinsurance for INR 
monitoring services provided by an out-of-network (OON) provider on January 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from August 18, 2021, to August 31, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you do not agree with the charges. 
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 $0 per 
day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
SNF Dates Benefit Days Copayment 
June 22, 2021  July 9, 2021 1-18 (18) $0/day 
August 18, 2021  August 19, 2021 19-20 (2) $0/day 
August 20, 2021  August 31, 2021 21-31 (11) $184/day 
Total:  $2,024 You have been asked to pay $184 per day for days 21-31 for the SNF care, for a total of $2,024. The SNF care 
falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from August 18, 2021, to August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on March 23, 2022. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. 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 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$33.33, which is 50% of the allowed amount for the OON INR monitoring ($66.67 allowed amount x 50% 
coinsurance = $33.33). The OON INR monitoring 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 coinsurance for INR 
monitoring services provided by an out-of-network (OON) provider on March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on February 23, 2022. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. 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 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$33.33, which is 50% of the allowed amount for the OON INR monitoring ($66.67 allowed amount x 50% 
coinsurance = $33.33). The OON INR monitoring 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 coinsurance for INR 
monitoring services provided by an out-of-network (OON) provider on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you called the office to tell 
them you had not received a return call yet. 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 $35 
copayment for each specialist visit, including telehealth services.  
 
The record shows that test results, evaluation, and treatment planning were discussed during a telehealth call on 
February 17, 2022. Therefore, you have been asked to pay a $35 copayment for the telehealth visit. The 
telehealth 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 a specialist telehealth visit provided on 
February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on December 3, 2021 
to December 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that the services were performed within the 90-day 
global surgical period for major procedure 49560 performed on November 21, 2021. Payment for these 
services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for 
the subsequent hospital care rendered on December 3, 2021 to December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails (11720) provided on March 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement. You say that the enrollee could not choose an in-network 
provider due to the Covid 19 pandemic. The Plan denied your request. The Plan says these services were 
provided out-of-network and were not 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 the debridement of nails (11720) provided on 
March 8, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee's plan termed May 31, 2022. The request would need to go 
through the insurance company the member is enrolled with. 
 The Plan must follow Medicare rules. Medicare rules say that a member may request disenrollment from an 
MA plan only during one of the election periods outlined in 30 and 30.7.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an Intracept device have not been met. Therefore, we decided that the Plan does not have to pre-
approve an Intracept device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 12, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg replacement. 
 
You asked the Plan to pre-approve a prosthetic leg replacement. You say that the services are 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. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a prosthetic leg replacement have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthetic leg replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on October 1, 2021. 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81479) provided on October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for bladder lesion treatments performed from 
January 10, 2022, to January 24, 2022. 
 
You asked the Plan to waive the copayments for the bladder lesion treatments. You say that the Plan did not 
pay anything on the claims. 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 $250 
copayment for each outpatient surgery or service at an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for each of the 3 bladder lesion treatments, for a total of $750. 
The bladder lesion treatments fall within the 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 copayments for bladder lesion treatments performed from January 10, 2022, to January 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR monitoring services provided by an 
out-of-network (OON) provider on December 29, 2021. 
 
You asked the Plan to waive the coinsurance for the OON INR monitoring. You say that the test site changed 
without permission. 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 50% 
coinsurance for out-of-network diagnostic procedures and tests.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$40.85, which is 50% of the allowed amount for the OON INR monitoring ($81.70 allowed amount x 50% 
coinsurance = $40.85). The OON INR monitoring 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 coinsurance for INR 
monitoring services provided by an out-of-network (OON) provider on December 29, 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 January 23, 
2022 to February 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were 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. Our physician reviewer found you were admitted to the hospital for placement with malaise and weakness in the setting of a 
recent COVID-19 infection and multiple diseases existing at once (comorbidities). The record indicates that the 
admitting provider noted that admitting testing was essentially negative and that you required placement. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 
two or more midnights. The inpatient level of care was not medically necessary. 
 
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 January 23, 2022 to February 7, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered on August 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct Type of Bill 
(TOB) code.  
 
We looked at the file and Medicare rules. The file shows that the services were billed with the incorrect TOB 
code. Therefore, we decided that the Plan does not have to pay for the outpatient surgical services rendered on 
August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs of electronic connectors. 
 
You asked the Plan to pre-approve repairs of electronic connectors. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 repairs of electronic connectors. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested item 
exceeds the enrollee's medical needs and does not meet Medicare medical necessity criteria per LCA A52504 
and the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. The enrollee does not have any power options on the wheelchair. Furthermore, there is no evidence on the treating medical provider documentation of inability or 
upper extremity deficit that would not allow control an power options (if available). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repairs of electronic connectors have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repairs of electronic connectors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion services (99601 and 99602) provided on 
December 3, 2021. 
 
You asked the Plan to pay for codes 99601 and 99602. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. This 
means that CPT codes 99601 and 99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of codes 99601 and 99602 have not been met. Therefore, we decided 
that the Plan does not have to pay for the home infusion services (99601 and 99602) provided on December 3, 
2021.