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

 
We decided that the Plan does not have to waive the copayment for an electronic analysis of an implanted 
neurostimulator provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for an electronic analysis of an implanted neurostimulator. You say 
that you have never had a charge for this test in the past, and it has always been paid as part of the office visit. 
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 $20 
copayment for non-radiological diagnostic services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$20 copayment for an electronic analysis of an implanted neurostimulator. An electronic analysis of an implanted neurostimulator 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 an electronic analysis of an 
implanted neurostimulator provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 laboratory services provided on June 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 3, 2022, to January 4, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had outpatient 
surgery and were discharged the same day. 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 $350 
copayment per admission for inpatient hospital care.  
 
The record shows if you are admitted with the expectation that you will remain in the hospital overnight, but 
are discharged before midnight, it counts the day as an inpatient stay. The medical record shows you were considered an inpatient on January 3, 2022. You have been asked to pay a $350 copayment for an inpatient 
hospital stay. An 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 an inpatient hospital stay provided from January 3, 2022, to January 
4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 30, 2021, to December 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the provider was contracted and 
you do not understand why you owe the copayment. 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 $295 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from November 30, 2021, to December 15, 2021. Therefore, you have been asked to pay $295 per day for the first 5 days of inpatient care. The total for your stay is $1,475 
($295 copayment x 5 days = $1,475). The inpatient care falls within the Inpatient Hospital Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 30, 2021, to December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on June 22, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that the records required to reprocess the 
denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on June 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the nuclear stress test provided on August 
18, 2021. 
 
You asked the Plan to waive the deductible for the nuclear stress test. You say that the nuclear stress test has 
been attributed to Diagnostic Radiology services and applied to your deductible but the provider's billing 
department confirmed that a nuclear stress test is not a radiological procedure. The Plan denied your request. 
The Plan says the deductible was applied correctly. Per page 4-33 of the Plans 2021 EOC, nuclear studies fall 
under Outpatient Diagnostics - Radiological Diagnostic Services.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to Outpatient Diagnostics - 
Radiological Diagnostic Services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostics - Radiological Diagnostic Services. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $500 deductible which applies to nuclear stress tests. This cost sharing is a 
contractual obligation that had not been met at the time a nuclear stress test was received on August 18, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for the nuclear stress test provided 
on August 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
October 27, 2021, to November 17, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that when you started therapy 
you were told you only had a $20 copayment for each visit. You also say you are being billed another $100 for 
equipment used during therapy. 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 $20 
copayment for each physical therapy visit.  
 
 The record shows this claim was approved, and you only have a cost sharing amount for your physical therapy 
visits. You have been asked to pay a $20 copayment for each physical therapy visit on October 27, 2021, 
October 29, 2021, November 3, 2021, November 9, 2021, and November 17, 2021 ($20 copayment x 5 visits = 
$100). Physical therapy visits fall within the 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 physical therapy visits provided from October 27, 2021, to 
November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological services provided on October 8, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological services. You say that that it isn't your responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-
network visit. 
 
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 Ophthalmological services provided on October 8, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (breast), mRNA, gene expression profiling 
(81518) rendered by the out-of-network (OON) provider on April 19, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the oncology (breast), mRNA, gene expression profiling (81518) rendered by the out-
of-network (OON) provider on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin 
injections provided on August 3, 2021. 
 
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections. The Plan denied your request. 
The Plan says Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the bodys ability to 
heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its 
billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like 
acupuncture.The Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for 
neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic / vasopneumatic devices can be 
covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory 
lymphedema.  
 
The Plan must follow Medicare rules. Medicare rules say that documentation must clearly support the medical 
necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or 
subjective changes noted in swelling and/or pain within 12 visits. The rules says that the use of vasopneumatic 
devices may be considered reasonable and necessary for the application of pressure to an extremity for the 
purpose of reducing edema or lymphedema. The rules say that beginning in July 2015, claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Medicare rules say 
claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), 
vasopneumatic device, Prolotherapy and vitamin injections have not been met. Therefore, we decided that the 
Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office Visit services provided on September 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Office Visit services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Office Visit services provided on September 22, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are on a fixed dose of nighttime insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from June 12, 2020, to June 19, 2020. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you were told the 
rehabilitation would be covered in full without any copayments, and that the insurance was supposed to cover 
the stay in full. 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 $360 
copayment per day for days 1-5 for an inpatient rehabilitation stay. The contract also says there is a $0 
copayment after day 5.  The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,800, which is a $360 copayment per day for days 1-5 of an inpatient rehabilitation stay ($360 
copayment x 5 days = $1,800). There is no charge after day 5. An inpatient rehabilitation 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 an inpatient 
rehabilitation stay provided from June 12, 2020, to June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care services provided on 
August 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent Nursing Facility Care services. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network visit. 
 
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 services 
provided on August 10, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the coronary angiography provided on 
December 20, 2021. 
 
You asked the Plan to waive the cost share for coronary angiography. You say that you should not have to pay 
this bill because you called the Plan to confirm the facility was in-network. The Plan denied your request. The 
Plan says cost share 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 $1000 
deductible and 30% coinsurance for each out-of-network, Medicare-covered outpatient surgery at a hospital 
outpatient facility.  
  The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that your $1000 deductible applies 
to the coronary angiography. This cost sharing is a contractual obligation that had not been met at the time the 
coronary angiography was received on December 20, 2021. Therefore, $574.35 has been applied to meet the 
deductible. 
 
Since the $1000 deductible was met, you have also been asked to pay $878.37 for the coronary angiography. 
The allowed amount is $2,927.90 (30% x $2,927.90 = $878.37). 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 the Plan does not have to waive the cost for 
the coronary angiography provided on December 20, 2021.