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

 
We decided that the Plan does not have to waive the copayment for a urology visit provided on June 14, 2022. 
 
You asked the Plan to waive the copayment for a urology visit. You say that you were only seen for 5 minutes, 
and do not feel you should have to pay a copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a urology visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for a urology visit provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on July 08, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says similar to the referral requirements for care received from network providers (see 
Chapter 3, section 2.3), the enrollee must get a referral from their primary care provider (PCP) prior to getting 
care from out-of-network providers via their point-of-service (POS) benefit. If the enrollee does not get a 
referral, they will have to pay the full cost of any services you receive. A referral or prior authorization is never 
required for emergency care, urgently needed care when network providers are unavailable, and dialysis for 
members with ESRD who are temporarily out of the service area, and you will always pay your network cost 
shares in these scenarios. 
 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 surgery provided on July 08, 2020, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetes footwear provided on June 9, 
2022. 
 
You asked the Plan to waive the coinsurance for diabetes footwear. You say that you are unable to pay 
coinsurance amount. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for diabetes self-management training, diabetic services and supplies. The allowed amounts of 
these footwears total $200.24, resulting in a total coinsurance amount of $40.05. 
 
You have been asked to pay 20% coinsurance for diabetes footwear. This item/service falls within the diabetes 
self-management training, diabetic 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 diabetes footwear provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathy services received on July 21, 2022. 
 
You asked the Plan to pay for the services. You say that you were told that this would be covered as a specialist 
visit. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathy services received on July 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 13, 2022, to January 17, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. There was no SOFA 
criteria points met based on the submitted medical record. The review has determined that the records did not 
support that A41.9 - sepsis, unspecified organism - was an appropriate diagnosis for this stay. The records did 
not support the use of DRG 872 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 13, 2022, to January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services and an eye exam 
provided from May 16, 2022, to May 20, 2022. 
 
You asked the Plan to waive the copayment for laboratory services and an eye exam. You say that you were 
told you would not owe anything. The Plan denied your request. The Plan says this cost sharing was charged 
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 $10 
copayment for each Medicare-covered laboratory service. Your contract with the Plan also clearly says that you 
must pay a $20 copayment for each Medicare-covered exam to diagnose and treat diseases of the eyes. 
 
 
  You have been asked to pay a $10 copayment for each laboratory service, which is a total of $20 ($10 
copayments x 2 laboratory services = $20). Laboratory services fall within the Medicare-covered laboratory 
service benefit category. You have also been asked to pay a $20 copayment for an eye exam. Eye exams fall 
under the Medicare-covered exam to diagnose and treat diseases of the eye(s) 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 and an eye exam provided from May 16, 2022, to 
May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lenses (V2200) and polycarbonate or equal lenses 
(V2784), and to pay more for the frames (V2020) purchased on August 10, 2022. 
 
You asked the Plan to pay for the glasses. You say that the provider is billing for services you never received. 
You also say that you did not purchase eyeglasses at the time of this visit, and only had an exam and a 
glaucoma screening. The Plan denied your request. The Plan says this claim has processed correctly. The Plan 
also says your yearly benefit maximum was exhausted on the frames. 
 
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 $100 for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that your eyewear allowance was exhausted on the 
frames you purchased on this date of service. 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 
bifocal lenses (V2200) and polycarbonate or equal lenses (V2784), and to pay more for the frames (V2020) 
purchased on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72193 billed for date of service April 24, 
2022. 
 You asked the Plan to pay for procedure code 72193. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 72193 is bundled into payment for 
code 74176. 
 
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 72193 
is a column II code to column I code 74176. 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 72193 billed for date of service April 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroplasty surgery provided on April 26, 
2022. 
 
You asked the Plan to waive the copayment for arthroplasty surgery. You say that you were advised by the 
Plan that you had $0 responsibility after you paid $200. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 copayment for arthroplasty surgery. This item/service 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 arthroplasty surgery provided on 
April 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 25, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says providers must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on April 28, 
2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for inpatient hospital services. The allowed amount for the services was less than the enrollees 
coinsurance, therefore the enrollee is responsible for the lesser amount, $2,012.24. 
 
You have been asked to pay a 20% coinsurance for inpatient hospital services. This item/service 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 services on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on May 18, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision and 
eyewear benefit that exceeds Medicare coverage.  
 
We looked at the file, the Plans rules and the Medicare rules. The Plan only covers refractions when provided 
by the Plans vision care provider. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for 
an eye refraction provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3020 x 2), orthotics management and 
training (97760), and the office visit (99212) provided on December 20, 2021. 
 
You asked the Plan to pay for these items/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 foot orthotics are not covered by the 
Plan or by Medicare for your condition. Additionally, the services provided in this case are not a covered 
chiropractic benefit. 
 Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Additionally, the 
rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a 
subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation 
is appropriate treatment. 
 
The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Additionally, the records show that the services at issue are not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for the foot orthotics (L3020 x 2), orthotics 
management and training (97760), and the office visit (99212) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and examination provided on July 29, 2022, by 
an OON provider. 
 
You asked the Plan to pay for an office visit and examination. You say that in the past the physician has always 
sent your charges through your Medicare health insurance. 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 and examination provided on July 
29, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chemotherapy treatment provided on 
May 26, 2022. 
 
You asked the Plan to waive the coinsurance for a chemotherapy treatment. You say that you already met you 
maximum out of pocket for the year and should not owe this coinsurance. The Plan denied your request. The 
Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. You have been asked to pay $537.17, which is less than 
the 20% coinsurance you would need to pay for  Medicare Part B drugs. 
 
You have been asked to pay a $537.17 coinsurance for a chemotherapy treatment. This item/service falls within 
the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a chemotherapy treatment provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable Medical equipment (DME) 
supply provided on August 1, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you should not be responsible for the full 
20% coinsurance of the allowed amount as you found the same item online for less. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of the DME 
supply total $96.61, resulting in a coinsurance amount of $19.32. 
 
You have been asked to pay 20% coinsurance for DME. This item/service falls within the durable medical 
equipment (DME) and related 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 Durable Medical equipment (DME) supply provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) provided on June 7, 
2021. 
 
You asked the Plan to pay for the observation care. You say that the filing deadline was extended due to the 
Public Health Emergency that is still ongoing. The Plan denied your request. The Plan says the claim was not 
filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the observation care was not filed until June 17, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the initial observation care (99220) provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam dressing (A6213) provided on June 10, 2022. 
 
You asked the Plan to pay for procedure code A6213. 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 code A6213 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for the foam dressing (A6213) provided on June 10, 2022.