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

 
We decided that the Plan does not have to pay for an office visit provided on April 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were rendered to the enrollee out of 
good faith, and you did not know an authorization was needed. 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. Also, the service rendered was not urgent or emergent. 
 
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 provided on April 17, 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 inpatient hospital care provided from April 
12, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Inpatient hospital care (per admission).  
 
 
  You have been asked to pay a $325 copayment for inpatient hospital care (per admission). 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 April 12, 2022, to April 15, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an octagam injection (J1568) provided on 
March 24, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied correctly 
based on the services provided. 
 
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 a 20% coinsurance for the injection (allowed is $2,496.78 x 20% = $499.36). 
Octagam injections fall 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 copayment for an octagam injection (J1568) provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that these orthotics are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered 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.   
 
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. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure provided from 
October 26, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for an outpatient procedure. You say that if you had known how 
expensive these procedures would be, you would not have agreed to them. The Plan denied your request. The 
Plan says the copayments 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 $150 
copayment for in-network outpatient hospital surgery services (6 visits x $150 = $900). 
 
You have been asked to pay a $900 copayment for an outpatient procedure. An outpatient procedure falls 
within the In-Network Outpatient Hospital Surgery 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 an outpatient procedure provided from October 26, 2021, to December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an x-ray provided on February 24, 2022. 
 
You asked the Plan to waive the deductible for an x-ray. You say that you feel you are being double billed for 
this service. The Plan denied your request. The Plan says the deductible applied is correct. 
 
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 $750 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time an x-ray was received on February 24, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for an x-ray provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on March 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that you work with a number of doctor 
groups who are participating providers and use your laboratory exclusively. You say the enrollee does not go to 
the laboratory, so they are not using their out-of-network benefits. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The record shows the referring provider was out-of-network. Therefore, we decided that the 
Plan does not have to pay for the surgical pathology services provided on March 22, 2022, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for stress test provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for stress test. You say that the appointment wasn't any longer than 
a half hour, so you dont know why you must pay so much. The Plan denied your request. The Plan says the 
copayment applied 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 $110 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
You have been asked to pay $110 copayment for stress test. Stress tests fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for stress test provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and chiropractic care provided on January 5, 
2022, to January 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and chiropractic care. You say that you misunderstood the rules of 
your policy and went to the chiropractor you have seen for 15 years with good results. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan.. The Plan did not pre-approve the 
office visit and the chiropractic care. We found no exception that would require the Plan to pay for the office 
visit and the chiropractic care. Therefore, we decided that the Plan does not have to pay for the office visit and 
chiropractic care provided on January 5, 2022, to January 14, 2022, 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 Lumbar-sacral orthosis (L0648) provided 
on March 7, 2022. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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 Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the lumbar-sacral orthosis (allowed is $760.38 x 20% = 
$152.07). Lumbar-sacral orthosis 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 Lumbar-sacral orthosis (L0648) 
provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of critical care billed with code 99292 for date 
of service June 18, 2021. 
 
You asked the Plan to pay for a second unit of 99292. You say that these services were reported appropriately. 
The Plan denied your request. The Plan says a second unit of 99292 is not supported in the medical record for 
this date of 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. 
 
In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). Code 99292 is an add on code for code 99291, which is defined as critical care, evaluation 
and management of the critically ill or critically injured patient; first 30-74 minutes. 
 
We find that a second unit of CPT code 99292 is not supported in the medical record. Specifically, the medical 
record notes that the total critical care time provided on the date in question was 90 minutes. The first 74 
minutes of these services are covered by reported code 99291. The next 16 minutes are covered by the first unit of 99292. In order for a second unit of 99292 to be billed, the total time for critical care services should be 
greater than 104 minutes. Based on this information, we decided that Medicare rules for coverage of a second 
unit of 99292 have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of 
critical care billed with code 99292 for date of service June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) provided on July 27, 2021. 
 
You asked the Plan to pay for the frames. You say that you are requesting a $160.00 which you paid as a down 
payment for your prescription glasses. The Plan denied your request. The Plan says you have exhausted your 
supplemental vision benefit for the 2021 Plan benefit year. 
 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 up to $150 for eyeglasses or contacts per plan year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan provided you with a $150 allowance 
towards glasses on July 26, 202. Based on this information, we decided that the Plan's rules for coverage of the 
frames have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) 
provided on July 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy is generally is not accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
patient has had prior extensive therapy approved for this condition and the documentation does not reveal that 
the patient  requires the unique skills of a professional therapist to safely and effectively provide treatment, that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and  the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient's current condition or to prevent or slow further deterioration. There has been ample sessions 
approved to provide thorough instruction in an independent home program. Ongoing skilled therapy is not 
medically necessary. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional physical therapy visits for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care provided in assisted living facility 
(Q5002), direct skilled nursing services of a registered nurse (RN) (G0299), services of clinical social worker (G0155), and direct skilled nursing services of a licensed practical nurse (LPN) (G0300) provided from January 
25, 2021, to February 22, 2021. 
 
You asked the Plan to pay for the services. You say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the medical records submitted do not meet the criteria 
for reimbursement. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that in 
this case, the documentation doesnt support that the enrollee requires additional skilled nursing services or 
social worker services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or social worker services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the members condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services are not medically necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health care provided in assisted living facility (Q5002), direct skilled nursing services 
of a registered nurse (RN) (G0299), services of clinical social worker (G0155), and direct skilled nursing 
services of a licensed practical nurse (LPN) (G0300) provided from January 25, 2021, to February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a total hysterectomy performed on May 3, 
2022. 
 
You asked the Plan to waive the copayment for the hysterectomy. You say that you were told you would be an 
inpatient due to your condition and should have a $0 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 a $100 
copayment for outpatient procedures or surgery at an outpatient hospital.  
 
The file shows that you were kept in the hospital under observation status following the procedure. For this 
reason, the procedure is still considered outpatient. Therefore, you have been asked to pay a $100 copayment 
for the hysterectomy. The hysterectomy 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 a total hysterectomy performed on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in a coronary artery for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show that this service is reasonable or necessary. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. The patient has not had evidence of chest pain or a change in cardiac status. The guidelines do 
not support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization 
would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter placement in a coronary artery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation provided on April 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 telephone evaluation provided on April 22, 2022, 
by an out-of-network (OON) provider.