Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye surgeries performed on May 17, 2021, 
and June 3, 2021. 
 
You asked the Plan to waive the copayments for the eye surgeries. You say that you were unaware of the extra 
charges for the procedure. 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 $245 
copayment for outpatient surgery services.  
 
You have been asked to pay a $245 copayment for each of the eye surgeries, for a total of $490. The eye 
surgeries fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for eye 
surgeries performed on May 17, 2021, and June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says the member does 
not meet Medicare criteria for coverage of the SNF services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
patient requires the services on an inpatient basis, only in a skilled nursing facility setting. Services in the 
assisted living facility with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive eye examination provided on  
November 16, 2021. 
 
You asked the Plan to pay for the comprehensive eye examination. You say that you were told to see another 
provider for another eye exam because the eyewear prescription was incorrect. The Plan denied your request. 
The Plan says that the Plan covers only one supplemental routine eye exam every year. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
up to one supplemental routine eye exam every year. 
 
We looked at the file and the Plan's rules. The file shows that you received the supplemental routine eye exam 
benefit on May 19, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive eye 
examination provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services you received from 
November 19, 2021, to November 29, 2021. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you have never been 
charged for services before and you cannot afford it. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 dialysis services.  
 
You have been asked to pay 20% coinsurance for the dialysis services. 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 dialysis services you received from November 19, 2021, to November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 27, 2021. 
 
You asked the Plan to pay for ambulance services. You say that you should not have to pay anything for these 
services. The Plan denied your request. The Plan says the member has other insurance as primary and this Plan 
as secondary. To process this claim we need an Explanation of Benefits from the primary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an Explanation of Benefits from the primary insurance carrier. As the secondary insurer, the Plan cannot be 
held responsible for ambulance services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion services you received at an 
outpatient hospital facility on March 17, 2021. 
 
You asked the Plan to waive the copayment for the hospital infusion services. You say that in previous years 
you paid less than $40 for this service. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that in 2020, it incorrectly charged you a lower copayment.  The Plan has 
decided not to go back and change the 2020 claims to charge you more, however, the cost sharing for 2021 is 
accurate. 
 
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 per visit for outpatient hospital services.  
 You have been asked to pay a $275 copayment per visit for the hospital infusion services. The hospital infusion 
services fall 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 infusion services you received at an outpatient hospital facility on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care you received 
from July 21, 2021, to July 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health care. You say that you were never 
told that you were going to be admitted to the hospital and you were not a threat to yourself.  You said that you 
should not have to pay the copayment. The Plan denied your request. The Plan says you were charged this 
copayment 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 $145 
copayment per day for days 1-10 for inpatient mental health care.  
 
 Records show that you received inpatient mental health care for 7 days.  You were charged a $145 copayment 
per day for a total of $1,015. This copayment applies regardless of the reason for the services. 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 mental health care you received from July 21, 2021, to July 
28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing 
services identified. The documentation does not support that it is medically reasonable and necessary to 
provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on January 5, 
2021, and July 20, 2021. 
 
You asked the Plan to waive the copayments for specialist visits. You say that your benefits say that you do not 
owe anything for office visits. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for specialist visits. 
 
You had a specialist visit on January 5, 2021. Therefore, you are responsible to pay the $35 copayment.  
 
You had a specialist visit on July 20, 2021. Therefore, you are responsible to pay the $35 copayment. 
 
The total amount you owe is: $70.  You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall within 
the physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for specialist visits provided on January 5, 2021, and July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on October 
14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the facility requested this provider 
be called in to see the patient as an attending provider in an outpatient capacity. You also say that there is a 
medical necessity pre-established with the patient and the facility, for this provider to provide services to the 
patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan, and the referring provider is non-participating. The Plan also says that they have also determined that 
these services are not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided 
on October 14, 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 gradient compression wrap identified with code 
A6545.  
You asked the Plan to pre-approve the compression stockings. You say that the wraps are the best solution. The 
Plan denied your request. The Plan says the request does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
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. 
 
We looked at the file and the rules. 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 a 
gradient compression wrap identified with code A6545.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Esophagogastroduodenoscopy (43239) 
provided on May 12, 2021. 
 
You asked the Plan to waive the copayment for the Esophagogastroduodenoscopy. You say that the services 
should be covered in full and the charges should be reversed as they have been before. The Plan denied your 
request. The Plan says the cost-sharing applied correctly based on the billed services. 
 
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 an Esophagogastroduodenoscopy. 
Esophagogastroduodenoscopy services fall within the Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an Esophagogastroduodenoscopy (43239) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the knee (73562) and the office visit 
(99214) rendered by the out-of-network (OON) provider on September 16, 2020. 
 
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. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services 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 x-ray exam of the knee (73562) and the office visit (99214) rendered by the 
out-of-network (OON) provider on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from October 2, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you began your 
stay at one hospital, but there were no beds to handle your extended treatment.  You said that there were beds at 
another facility, so you were transferred thered.  You do not feel as though you should have to pay the 
copayment for this admission. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that you had two separate admissions at different hospitals, so the copayment applied 
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 $400 copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $400 copayment per day for days 1-5 for the inpatient hospital services. 
According to your contract, you pay a copayment per admission.  You had different admissions at different 
facilities, so separate copayments can apply. 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 you received from October 2, 2021, to October 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on November 3, 
2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you were told this procedure would 
be covered completely. The Plan denied your request. The Plan says the copayment applied was 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 $325 
copayment for each Medicare-covered outpatient surgery at an in-network hospital outpatient facility.  
 
You have been asked to pay a $325 copayment for an endoscopy. An endoscopy 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 an endoscopy provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80048, 85025, 87493), the travel 
allowance one way in connection with medically necessary laboratory specimen collection drawn from a home 
bound or nursing home bound patient; prorated trip (P9604), and the collection of venous blood by 
venipuncture or urine sample by catheterization from an individual in a skilled nursing facility or by a 
laboratory on behalf of a home health agency (G0471) rendered by the out-of-network (OON) provider on 
November 1, 2021. 
 
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. 
 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 services at issue in this appeal. The Plan did not pre-approve the services 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 laboratory services (80048, 85025, 87493), the travel allowance one way in 
connection with medically necessary laboratory specimen collection drawn from a home bound or nursing 
home bound patient; prorated trip (P9604), and the collection of venous blood by venipuncture or urine sample 
by catheterization from an individual in a skilled nursing facility or by a laboratory on behalf of a home health 
agency (G0471) rendered by the out-of-network (OON) provider on November 1, 2021.