Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation/. The Plan denied your request. The Plan says that the denied services are not a 
covered benefit as there is no evidence to support the referring/ordering provider is/was treating the patient 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage for the laboratory services by stating 
that they reached out to the ordering providers office and confirmed no testing was ordered. This stands in 
opposition to the signed testing order form that was provided in the case file. Medical records from the ordering 
provider for the enrollee were also received indicating the provider has seen the enrollee. There is insufficient 
proof available to conclude the testing was not ordered by the physician in question. Therefore, we decided that 
the Plan has to pay for the laboratory services provided on April 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), the chiropractic 
manipulative treatment (98941), and the extra-spinal chiropractic manipulation treatment (98943) provided 
from March 11, 2022, through March 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 Plan contract says that enrollees are covered up 
to 20 visits per year of routine chiropractic services (combined with acupuncture services). Enrollees must use 
the Plans contracted routine chiropractic provider for chiropractic services. 
 
 The records show that the services at issue in this case were rendered by an out-of-network provider, without 
prior authorization. The Plan contract says that you must use the Plans contracted routine chiropractic provider 
for chiropractic services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises 
(97110), the chiropractic manipulative treatment (98941), and the extra-spinal chiropractic manipulation 
treatment (98943) provided from March 11, 2022, through March 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 20, 2021, to 
August 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that you did not know the provider was out-of-
network. The Plan denied your request. The Plan says these services were received by an out-of-network 
provider and 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 physical therapy services provided on July 20, 
2021, to August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery performed on May 25, 
2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you were not informed of any 
copayment. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for outpatient procedures and services, other than colonoscopies, performed at an outpatient 
hospital or ambulatory surgical center.  
 
You have been asked to pay a $350 copayment for the cataract surgery. The cataract surgery falls 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 copayment for cataract surgery performed 
on May 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services with no transport received on September 
18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says emergency medical services (EMS) response without transport is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services with no transport received on 
September 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 22, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you went for you annual visit and 
had to return the next day for blood work. The Plan denied your request. The Plan says you were charged this 
cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 per 
day for laboratory tests that are not FIT tests.  
 
You have been asked to pay $10 for the lab services. The lab services fall 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 laboratory services provided on April 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on December 25, 2021. 
 
You asked the Plan to pay for the radiology services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this patient was enrolled in hospice on the date 
of service in question. 
 
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 radiology services provided on December 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83789, G0480, 80307) provided on 
April 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 (83789, G0480, 80307) 
provided on April 21, 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 debridement services (97597) provided on April 15, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 debridement services (97597) provided on April 
15, 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 medical services provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have submitted medical records to 
support payment. 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 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 medical services provided on June 10, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Humidifier (E0562) provided on February 26, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the Humidifier. You say that the items should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the items denied correctly as they were non-emergent 
and prior authorization was not 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 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 Humidifier (E0562) provided on February 26, 
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 copayments and coinsurance for ferumoxytol infusions 
provided from April 13, 2022, to April 20, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the infusions. You say that you were not 
informed of any cost sharing for the services. The Plan denied your request. The Plan says you were charged 
this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for surgery or other services provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $215.25 for the administration of each infusion, which is less than the $295 
copayment per the EOC. The infusion administration falls within the Outpatient Surgery, Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also 
been asked to pay $69.67 for each of the ferumoxytol drugs, which is 20% of the allowed amount ($348.33 
allowed amount x 20% coinsurance = $69.67). The ferumoxytol drugs fall within the Medicare Part B 
Prescription Drugs benefit program. The total for all services is $569.84. 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 and coinsurance for ferumoxytol infusions provided from April 13, 2022, to April 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 8, 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 March 21, 2022, to April 11, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you thought the entire stay was 
covered in full. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per 
day for days 1-20 and $188 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Period Days Copayment 
March 21, 2022  April 9, 2022 1-20 $0/day 
April 10, 2022  April 11, 2022 21 $188/day 
Total:  $188 You have been asked to pay $188 per day for day 21 of SNF care. 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 March 21, 2022, to April 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient diagnostic and therapy visit on 
April 07, 2022. 
 
You asked the Plan to waive the copayments for outpatient diagnostic and therapy visit. You say that you want 
to appeal the amount being charged. 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 $80 
copayment for diagnostic procedures/tests. Covered services include but are not limited to other outpatient 
diagnostic tests. You must pay a $30 copayment for each Medicare-covered therapy visit, $900 annual 
maximum out-of-pocket cost combined with acupuncture. Covered services include physical therapy, 
occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various 
outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive 
Outpatient Rehabilitation Facilities (CORFs). $80 + 30 = $110. Therefore, results in the total cost sharing 
amount of $110.  
 
You have been asked to pay a $80 copayment for outpatient diagnostic and therapy visit. Outpatient diagnostic 
and therapy visits fall within the Outpatient diagnostic tests and therapeutic services and supplies and 
Outpatient rehabilitation 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 copayments for 
outpatient diagnostic and therapy visit on April 07, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2021, to April 
8, 2021. 
 
You asked the Plan to pay for home health services. You say that you have tried to get the provider to bill a 
corrected claim. The Plan denied your request. The Plan says this claim was billed with a missing code and the 
Plan is not responsible for balance billing. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee. The rules also say that home health agencies must report where home health services were provided 
using code Q5001, Q5002, or Q5009. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the record indicates that the claim at issue was not billed with the required code to indicate where the home health services were provided, and the Plan 
denied this with no allowed amount or enrollee responsibility. A Medicare provider should accept the Medicare 
Allowed Amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains 
after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for home health 
services provided from April 1, 2021, to April 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient services and office visit on May 
27, 2022. 
 
You asked the Plan to waive the copayments for outpatient services and office visit. You say that you want to 
appeal the amount being charged. 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 $350 
copayment for each outpatient surgical service. We cover medically-necessary services you get in the 
outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include 
but are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery.  You must pay a $40 copayment for each Medicare-covered specialist visit. Covered services include 
consultation, diagnosis, and treatment by a specialist. $350 + $40 = $390. Therefore, results in the total cost 
sharing amount of $390.  
 
You have been asked to pay a $350 copayment for outpatient services and a $40 copayment for office visit. 
Outpatient services and office visits fall within the Outpatient hospital services and 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 copayments 
for outpatient services and office visit on May 27, 2022.