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

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observations, an office 
visit and a mental health visit provided from May 2, 2022, to June 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital observations, an office visit and mental 
health visit. You say that you do not feel you were under observation. 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 $225 
copayment per visit for outpatient hospital observation, a $40 copayment for outpatient mental health care/in person outpatient mental health and a $45 copayment for a physician/practitioner services/specialist visit.  
 
You have been asked to pay a $225 copayment per visit for outpatient hospital observations, a $40 copayment 
for a mental health visit, and a $45 copayment for a specialist office visit. The total amount you are being asked 
to pay is $535 ($225 (May 3, 2022) + $225 (June 13, 2022) + $40 + $45 = $535). 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 observations, an office visit and a mental health visit provided 
from May 2, 2022, to June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis, tumor immunohistochemistry 
services coded 88360 provided on January 7, 2022. 
 You asked the Plan to pay for the morphometric analysis, tumor immunohistochemistry services. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 88360 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. This claim was billed with a place of service 22, outpatient hospital. The 
professional interpretation was furnished in the same payment locality from where the technical component 
was furnished. The Medicare rule for payment of this claim has not been met as the professional interpretation 
of a diagnostic test must be separately billed with modifier  26 by the interpreting physician. Based on this 
information, we decided that Medicare rules for coverage of the morphometric analysis, tumor 
immunohistochemistry services have not been met. Therefore, we decided that the Plan does not have to pay 
for the morphometric analysis, tumor immunohistochemistry services coded 88360 provided on January 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the referring provider is not a network provider, and authorization was not 
obtained prior to services being rendered. 
 
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 genetic testing provided on March 9, 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 a specialist office visit provided on June 
29, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you did not see the doctor 
that day. 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 $15 
copayment for Physician/Practitioner services/outpatient specialist.  
 
You have been asked to pay a $15 copayment for specialist office visit. This item/service falls within the 
Physician/Practitioner services/outpatient specialist 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 specialist office visit provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthopedic visit provided on March 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an orthopedic visit. You say that you made this appointment with a Plan 
representative, and they never told you this provider was not in-network. 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 orthopedic visit provided on March 18, 2022, 
by an out-of-network (OON) provider.   
Your complaint about the Plan representative not telling you about the out-of-network provider is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on June 06, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $65 
copayment for out-of-network provider and professional services at primary care providers (PCP) office and 
specialists office. Covered services include consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $65 copayment for office visit. This item/service falls 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 copayment for office visit on June 06, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on June 3, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you cannot prevent other people from 
calling for an ambulance. The Plan denied your request. The Plan says this service is not covered when there is 
no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on June 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided by Peterson Regional 
Medical Center on October 13, 2021, to October 14, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital services have been 
met. Medical records were not provided. Without medical records, a favorable decision cannot be determined. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided by Peterson 
Regional Medical Center on October 13, 2021, to October 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on September 8, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you were advised you would save money 
by not taking the ambulance. The Plan denied your request. The Plan says this service is not covered when 
there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on September 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay from 
January 25, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you feel that you should not owe the 
balance for the services you received. 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 through 20 and a $188 copayment per day for days 21 through 100 for skilled 
nursing facility (SNF) care.  
 
You have been asked to pay a $2,068 copayment for a SNF stay. This item/service falls within the skilled 
nursing facility (SNF) care benefit category. Please see the next page for a breakdown of your cost-share. 
 
 You were admitted to the SNF on January 25, 2022. For the first 20 days, you did not have to pay a copayment. 
However, from days 21 through 31, a copayment was assessed ($188 copayment  11 days = $2,068). 
 
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 skilled nursing facility (SNF) stay from January 25, 2022, 
to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee needs this to help her breathe 
correctly. The Plan denied your request. The Plan says the documentation does not support that a CPAP or 
BiPAP would not meet the enrollee's medical needs. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our physician reviewer 
found that the enrollee has COPD. She was recently hospitalized with exacerbation of COPD and heart failure 
with preserved ejection fraction (HFpEF). The arterial blood gas (ABG) was consistent with acute on chronic 
hypercarbic respiratory failure, with very severe increase in the partial pressure carbon dioxide (PaCO2). It is 
likely the enrollee has chronic CO2 retention and may benefit from BiPAP during sleep as an outpatient. 
However, Medicare does not cover a home ventilator when used as BiPAP. Therefore, a home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on June 3, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that it was not necessary to be transported to 
the hospital. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 3, 2022. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee receives their care from a network provider. In most cases, care the 
enrollee receives from an out-of-network provider will not be covered. Chapter 3 provides more information 
about requirements for using network providers and the situations when we will cover services from an out-of-
network provider. 
 
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 provided on June 23, 2022, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a skilled nursing facility stay provided 
from May 4, 2022, to May 10, 2022. 
 
You asked the Plan to waive the coinsurance for a skilled nursing facility stay. You say that you thought you 
were covered 100% for a SNF stay. No copayments, coinsurance, etc. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for skilled nursing facility (SNF) care. The allowed amount of this service or item is $3617.24, 
resulting in a coinsurance of $347.35 ($3617.24 x 10% = $347.35), which is less than the 10%. 
 
You have been asked to pay a $347.35 coinsurance for a skilled nursing facility stay. This item/service falls 
within the skilled nursing facility (SNF) 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 coinsurance 
for a skilled nursing facility stay provided from May 4, 2022, to May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 07, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says it is important to know which providers are part of our network because, with 
limited exceptions, while the enrollee is a member of our plan the enrollee must use network providers to get 
their medical care and services. The only exceptions are emergencies, urgently needed services when the 
network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and 
cases in which the Plan authorizes use of out-of-network providers. See Chapter 3 (Using the plan's coverage 
for your medical services) for more specific information about emergency, out-of-network, and out-of-area 
coverage. 
 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 lab testing provided on June 07, 2022, 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 home ventilator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
advanced capability is available on a BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 requested services. Our physician 
reviewer found that the enrollee has COPD, severe obesity with likely obesity hypoventilation syndrome. He 
was hospitalized in June 2022 with an arterial blood gas (ABG) consistent with acute on chronic hypercarbic 
respiratory failure. Partial pressure carbon dioxide (PaCO2) improved rapidly on BiPAP. There is no ABG 
done while stable as an outpatient, but chronic CO2 retention seems likely. The enrollee may benefit from 
BiPAP during sleep. However, Medicare does not cover a home ventilator when used as BiPAP. Therefore, a 
home ventilator 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the procedure was recommended by another 
provider, and it was performed because you did not want to be a barrier to medical care. The Plan denied your 
request. The Plan says the service was denied as the provider is a not contracted with the Plan. 
 
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 March 8, 2022, by an 
out-of-network (OON) provider.