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

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 30, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are appealing the 
copayment. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $50 
copayment for specialty care physician.  
 
You have been asked to pay a $50 copayment for a specialty visit. The specialist visit 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 a specialist visit provided on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ambulance transportation provided on 
January 10, 2022. 
 
You asked the Plan to waive the copayment for Ambulance transportation. You say that the enrollee's 
ambulance transfer should be covered since this was part of the hospital's treatment plan. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment per one-way trip for Ambulance transportation.  
 
The enrollee has been asked to pay a $200 copayment per one-way trip for Ambulance transportation. 
Ambulance transportation falls within the Ambulance services category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for Ambulance transportation provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the requested provider is an out-of-network provider and 
the service requested may be provided by participating providers 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 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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sigmoidoscopy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the sigmoidoscopy. You say that the service was medically necessary. 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 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. We found no exception that would 
require the Plan to pre-approve the sigmoidoscopy. The records provided for review do not show that the 
service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the 
sigmoidoscopy to be provided 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 mental health care provided from 
December 20, 2021, to December 31, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $245 copayment per day for days 1-6 of Inpatient mental health care.  
 
 
  The enrollee has been asked to pay a $1,470 copayment for 6 days of inpatient mental health care ($246 x 6 = 
$1,470). This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental health care 
provided from December 20, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (97803) rendered by an out-of-
network (OON) provider on November 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.  We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the medical nutrition therapy (97803) rendered by an out-of-network (OON) provider 
on November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0429) 
provided on August 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. 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 $275 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $275 copayment for the ambulance transportation 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 ambulance transportation services (A0429) provided on August 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the copay 
and would like the service covered. The Plan denied your request. The Plan says the copayment was 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 $35.00 
copayment for each visit for Medicare-covered specialist services received in a network providers office. 
 
 
  You have only been asked to pay $20.16 for the specialist office visit which is less than the standard $35 
copayment. Specialist office 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 copayment for the specialist office visit 
provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043), the initial 
nursing facility care, per day (99305), the subcutaneous tissue debridement (11042), and the chemical 
cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on July 13, 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 muscle and/or fascia debridement (11043), the initial nursing facility care, per 
day (99305), the subcutaneous tissue debridement (11042), and the chemical cauterization of granulation tissue 
(17250) rendered by the out-of-network (OON) provider on July 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 5, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were denied correctly. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on 
January 5, 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 the outpatient hospital services rendered by the out-of-
network (OON) provider on December 14, 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 outpatient hospital services rendered by the out-of-network (OON) provider 
on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient hospital services provided on December 13, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient hospital services. 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 authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Outpatient hospital services provided on 
December 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the breast prostheses provided by a network 
provider on December 17, 2021. 
 
You asked the Plan to waive the cost share for the breast prostheses. You say that you thought you had already 
met your deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to the breast prosthesis and 20% 
coinsurance which applies to all other in-network Medicare-covered prosthetic devices and supplies.  
 
The breast prostheses you asked the Plan to waive the cost share for falls within the Prosthetic devices and 
related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $300 deductible which applies to the breast prostheses and 20% coinsurance which applies to all 
other in-network Medicare-covered prosthetic devices and supplies. See chart below. Date of Service Service Allowed Amount Deductible/ 
Coinsurance 
Member Liability 
December 17, 2021 Breast prosthesis $127.77 $300 $127.77 
December 17, 2021 Breast prosthesis, 
silicone 
$351.55 $300 $172.23  This is 
where you met 
your $300 
deductible 
amount. 
December 17, 2021  $179.32  This is the 
remaining allowed 
amount after the 
deductible was applied. 
20% $35.86 
Total    $335.86 
 
This cost sharing is a contractual obligation that had not been met at the time the breast prostheses was received 
on December 17, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the breast 
prostheses provided by a network provider on December 17, 2021. 
  
Your complaint about the benefit design 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient 
hospital care does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found you have a planned total knee replacement surgery. There are no 
complicating medical factors noted in the medical record. This procedure is not on the CMS inpatient only list 
and there is no submitted rationale that supports a need for medically necessary care that would span greater 
than two midnights. The record does not show that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin graft services (15275) provided on May 12, 2021. 
 
You asked the Plan to pay for the skin graft services. You say that you would like this claim reprocessed and 
approved for payment based on the medical records. The Plan denied your request. The Plan says the operative 
report does not support payment for the code 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. 
 
In this case, the CPT Code Manual definition of code 15275 is application of skin substitute graft to face, scalp, 
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 
100 sq cm; first 25 sq cm or less wound surface area. 
 
We asked our coder 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 skin graft services. Our reviewer says that the 
documentation does not support payment for the skin graft services coded as CPT 15275. Our reviewer found Procedure report does not support (Affinity) as a skin substitute. Per the CPT assistant, it is not appropriate to 
report code 15271, Application of skin substitute graft, for the application of micronized/ powdered human 
allograft. The micronized/powdered form does not involve fixation; rather, it is placed like a dressing. It is 
similar in work to putting on a dressing, such as antibiotic ointment. The skin replacement surgery guidelines 
in the Integumentary section of the CPT code set indicate that the skin substitute graft codes are not to be 
reported for application of non-graft wound dressings (eg, gel, powder, ointment, foam, liquid) or injected skin 
substitutes. Application of non-graft wound dressings is not separately reportable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skin graft services have not been met. Therefore, we decided that the Plan 
does not have to pay for the skin graft services (15275) provided on May 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services provided 
on December 14, 2021, and January 19, 2022 
 
You asked the Plan to waive the copayment for the outpatient mental health services. 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 $40 
copayment for Outpatient mental health care.  
 
 You have been asked to pay an $80 copayment for two outpatient mental health visits ($40 x 2 = $80). 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 mental health services provided on December 14, 
2021, and January 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health care (90837) provided from 
January 3, 2022, to January 31, 2022. 
 
You asked the Plan to waive the copayment for the mental health care. You say that the services should be 
covered as you disagree with the charges and were under the impression that you would pay $35 per visit. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits, specifically telehealth specialist 
visits.  
 You have been asked to pay a $160 copayment for 4 mental health care visits ($40 x 4 = $160). The record 
indicates that these services were performed through telehealth and based on your contract with the plan; 
specialist tele-health services will assess a $40 copayment each. 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 mental health care (90837) provided from January 3, 2022, to January 31, 2022.