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

 
We decided that the Plan has to waive the copayments for a skilled nursing facility (SNF) stay provided from 
May 1, 2022, to May 25, 2022. 
 
You asked the Plan to waive the copayments for the SNF stay. You say that you were told your stay would be 
covered. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay per day for days 21 to 100 in a SNF.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $194.50 
copayment per day for days 21 to 100. The Plan contract does not clearly say how much enrollees must pay per 
day for days 21 to 100 in a SNF. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the copayments for a skilled nursing 
facility (SNF) stay provided from May 1, 2022, to May 25, 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 physical therapy services (97161) provided on April 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the out-of-network services were not pre-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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for physical therapy services (97161) provided on April 12, 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 physician services (99204) provided on July 20, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service cannot be paid 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 code 99204 is not supported in the medical record. Specifically, minor procedure 20552 with 
a global surgery period of 0 days was billed on the same date of service. The evaluation and management 
service (99204) is included in the surgical procedure and is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services (99204) provided on July 20, 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 May 1, 2022, to May 26, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you thought the plan would pay for 
everything. 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 $0 
copayment per day for days 1-20 and $188 per day for days 21-100 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $0 copayment per day for days 1-20 and $188 per day for days 21-100 for SNF 
care. The total amount you are being asked to pay $1,880 ($188 x 10 days = $1,880). 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 May 1, 2022, to May 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 8, 
2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are disputing the share cost. 
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 $120 
copayment for emergency care.  
 
You have been asked to pay $120 copayment for emergency care. This item/service falls within the emergency 
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 emergency care provided on 
August 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of a benign lesion including margins, except 
skin tag, trunk, arms or legs (11406) provided on July 11, 2022. 
 
You asked the Plan to pay for the excision of a benign lesion including margins, except skin tag, trunk, arms or 
legs (11406). You say that the surgical assistant was chosen by the operating surgeon completely at the 
surgeon's discretion. Youi also say the surgical assistant provider had no choice to be not on the case and 
ethically could not deny the services to the patient. The Plan denied your request. The Plan says procedure code 
11406 is listed as non-payable on the Centers for Medicare and Medicaid Services (CMS) assistant surgery list. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11406. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
excision of a benign lesion including margins, except skin tag, trunk, arms or legs (11406) have not been met. 
Therefore, we decided that the Plan does not have to pay for the excision of a benign lesion including margins, 
except skin tag, trunk, arms or legs (11406) provided on July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on June 30, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 code 0037U is not supported in the medical record. Specifically, the date of service billed 
does not match the date on which the specimen was obtained (June 23, 2022). Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for genetic testing (0037U) provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 9, 2022. 
 
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 this service is not a covered benefit by the 
Plan or by Medicare. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The 
Plan denied your request. The Plan says you do not have documentation of a qualifying wound requiring 
treatment. The requested gradient compression stockings are therefore statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01936) provided on August 31, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 code 01936 is not supported in the medical record. Specifically, the date on the anesthesia 
report (August 17, 2021) does not match the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (01936) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
July 11, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with the amount you have to pay. 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. 
 
You have been asked to pay 20% coinsurance for durable medical equipment. 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 provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the homes health visit. You say that you would like the claim processed for 
payment. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. 
  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 home health visit provided on July 22, 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 copayment for outpatient surgery provided from January 
11, 2022 to May 18, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that your cost-sharing 
obligation was improperly assessed on the claims at issue. 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 $275 
copayment for Medicare-covered surgical services performed in an outpatient department of a hospital.  
 
 
 You have been asked to pay a total of $1,100.00 ($275 x 4 visits = $1,100.00). Outpatient 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 outpatient surgery provided from 
January 11, 2022 to May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle-foot system microprocessor 
control power source (L5973) and lithium ion battery charger (L7368). 
 
You asked the Plan to pre-approve prosthetic foot components. You say that your prosthetic foot is broken. The 
Plan denied your request. The Plan says your activity needs can be met with a mechanical foot. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 prosthetic foot components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records provided do not adequately explain the need for a 
microprocessor ankle-foot system as opposed to a mechanical K3 level ankle-foot system. Additionally, a 
lithium ion battery charger is not needed as a battery charger is already included with the requested foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic foot components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an endoskeletal ankle-foot system microprocessor control power source 
(L5973) and lithium ion battery charger (L7368).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrical stimulation device provided on June 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electrical stimulation device. You say that this should be covered, decision 
made in error. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 electrical stimulation device provided on June 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchoscopy (31625, 31622, 31624, 31641) to be 
provided by an out-of-network (OON) provider at an in-network level. 
 
You asked the Plan to pre-approve a bronchoscopy. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this service is available by a provider in the enrollee's network. However, if the 
enrollee chooses to receive services from this out of network provider, his share of the cost for his covered 
services may be higher. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a bronchoscopy (31625, 31622, 31624, 31641) to be provided by an out-of-network (OON) provider at an in-
network level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on June 
28, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that on the date of service, 
you were told your only responsibility as $25, which you paid. You also say that you think it is not fair that 
now you received a bill for the refraction. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state (92015) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation (99395), lipid panel (80061), comprehensive metabolic panel (80053), and complete blood count 
(85025) provided on May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the office advised that they accepted your 
insurance. You say that it appeared that your visit would be covered. You also say that you cannot afford 
additional monthly costs. The Plan denied your request. The Plan says services that you receive out-of-network 
are 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 service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation (99395), lipid 
panel (80061), comprehensive metabolic panel (80053), and complete blood count (85025) provided on May 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital facility services on 
April 8, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital facility 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 $150 
copayment for outpatient hospital facility services.  
 
You have been asked to pay a $150 copayment for outpatient hospital facility services. This item/service falls 
within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient hospital facility services on April 8, 2022.