Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 15, 
2022, to June 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $260 
copayment for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 8 days, resulting in a 
copayment amount of $1,300 ($260 per day for 5 days = $1,300.00).  
 
You have been asked to pay $260 copayment for days 1 to 5 for inpatient hospital care. This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided on June 15, 2022, to June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam and the refraction provided on June 2, 
2022. 
 
You asked the Plan to pay for the medical eye exam and the refraction. You say that your coverage does not 
state a pre-approval was necessary, and that you get an eye exam with no charge. The Plan denied your request. 
The Plan says the provider was out-of-network.  
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 these services when they are received from a provider in the Plan's vision vendor 
network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the medical eye exam and the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the medical eye exam and the refraction 
provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 12, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee was seen in a facility 
and the facility should have obtained the prior authorization. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 provided on May 
12, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinalysis, cystourethroscopy and injection provided on May 
18, 2022, by an OON provider. 
 
You asked the Plan to pay for the urinalysis, cystourethroscopy and injection. You say that you had a prior 
authorization. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 urinalysis, cystourethroscopy and injection 
provided on May 18, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for session with licensed professional provided 
on August 26, 2021. 
 
You asked the Plan to waive the copayment for session with licensed professional. You say that you will not 
pay this bill. 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 $55 
copayment for outpatient mental health care.  
 
You have been asked to pay $55 copayment for session with licensed professional. This item/service falls 
within the outpatient mental health care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for session with licensed professional provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pneumatic walking boot provided on April 
27, 2022. 
 
You asked the Plan to waive the copayment for pneumatic walking boot. You say that you were not aware they 
would be charged for the boot. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for pneumatic walking boot. This item/service falls within the 
durable medical equipment (DME) 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 
pneumatic walking boot provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two levels of the facet blocks. We decided that the Plan does not 
have to pre-approve the third level of the facet block.  
 
You asked the Plan to pre-approve the Facet Injection, Lumbar/Sacral Level 1, 2 and 3 (64493, 64494, 64495). 
You say that the service is medically necessary. The Plan says that the service is not medically necessary. 
 
We decided that the Plan has to pre-approve two levels of the facet blocks.  
 
The Plan follows Medicare rules. Medicare rules say that one or two level, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 facet blocks. Our physician reviewer found that only two levels meet the criteria for diagnostic facet blocks and are reasonable and 
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 facet blocks have been met. Therefore, we decided that the Plan has to pre-
approve two levels of the facet blocks.  
 
We also decided that the Plan does not have to pre-approve the third level of the facet block. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal. 
 
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 third level of the facet block. Our 
physician reviewer found the third level exceeds utilization criteria and therefore is not considered medically 
reasonable and 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 third level of the facet block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the third level of the facet block. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psychotherapy (90853) and self-help or peer 
services (H0038) provided from June 23, 2022, to July 7, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the enrollee attends substance abuse 
rehabilitation. You also say that this is not a benefit that Medicare covers. The Plan denied your request. The 
Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the group psychotherapy (90853) and 
self-help or peer services (H0038) provided from June 23, 2022, to July 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 11, 2022, 
through February 9, 2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted on January 13, 2022, 
but the system changed the service date on the NOA. You say that the denial is an error, and the claim should 
be reconsidered for payment. The Plan denied your request. The Plan says a valid NOA was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, a valid NOA was not submitted. Therefore, 
we decided that the Plan does not have to pay for home health services provided from January 11, 2022, 
through February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for services provided from 
November 25, 2021, to November 27, 2021. You asked the Plan to pay for the billed services. You say that medical records were provided for review. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not document the total time that critical care services were 
furnished. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for 
services provided from November 25, 2021, to November 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for services provided on May 8, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the billing. The Plan 
denied your request. The Plan says the service was not billed as required by coding regulations. 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 99153 has a PC/TC indicator of 3. This is a technical component only code and not 
payable as billed. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for services provided 
on May 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scans provided on August 4, 2022, by an OON provider. 
 
You asked the Plan to pay for CT scans. You say that the provisions of Florida State statute 627.638 require 
that the insurers are responsible for processing claims for out-of-network providers when the facility is in-
network. The Plan denied your request. The Plan says the enrollee must receive care from a 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 CT scans provided on August 4, 2022, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pay for an eye examination and eye refraction provided on June 16, 2022.. You say that 
the enrollee should not be responsible for this charge because it was a routine examination. The Plan says that 
the deductible amount the enrollee is being charged is correct and the denial of payment for the eye refraction 
is correct. 
 
We decided that the Plan has to waive the deductible for the eye exam.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 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 says that enrollees 
must pay $800 deductible for all items and services. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a summary of all amounts applied to the enrollees 
2022 deductible. Without this information, we cannot determine whether the deductible had already been met 
at the time this claim was processed. Therefore, the Plan has not shown that its decision to ask the enrollee to 
pay $144.12 deductible amount is correct or justified according to the enrollees contract with the Plan. 
Therefore, we decided that the Plan has to pay for eye exam.  
 
We also decided that the Plan does not have to pay for refraction. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The eye refraction you asked the Plan to pay for is considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pay for refraction. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter placement in coronary artery(s) for coronary 
angiography (93458) and moderate sedation services (99152) provided on March 2, 2022. 
 
You asked the Plan to pay for the catheter placement and moderate sedation 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 include documentation for the billed date of service. The Plan also says there is insufficient 
documentation to corroborate the services, and it cannot be confirmed that Medicare coverage criteria has been 
met. 
 
 
 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 the catheter placement and moderate 
sedation services have been met. Medical records for the March 2, 2022, date of service at appeal were not 
provided with this case. The Plan asked for this information multiple times, but it was not provided. Without 
this information we cannot determine that the services provided were supported and medically necessary. 
Therefore, we decided that the Plan does not have to pay for the catheter placement in coronary artery(s) for 
coronary angiography (93458) and moderate sedation services (99152) provided on March 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 27, 2021, to 
July 21, 2021. 
 
You asked the Plan to pay for the skilled nursing services. The Plan denied your request. The Plan says your 
claims were received on August 4, 2022, which is outside of the 365 days allowed by Medicare. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the skilled nursing services was not filed until August 4, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing services provided from June 27, 2021, to July 
21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 14, 
2022, to June 15, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you think you should not 
pay the copayment 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 $390 
copayment for inpatient hospital care.  
 
You have been asked to pay $390 copayment for days 1 to 5 for inpatient hospital care. This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided on June 14, 2022, to June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the refraction provided on October 22, 
2022. 
 
You asked the Plan to pay for the office visit and the refraction. You say that your primary care doctor 
recommended that you have the eye doctor's appointment. The Plan denied your request. The Plan says the 
refraction is not a covered benefit, and the office visit was processed correctly. 
 
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 does not cover refractions. Also, 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 Medicare-covered specialist services. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not a covered service. Based on this 
information, we decided that the Plan's rules for coverage of the office visit and the refraction have not been 
met. You have also been asked to pay a $50 copayment for the office visit. The office visit falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct cost-sharing amount. Therefore, we decided that the Plan does not have to pay for the 
office visit and the refraction provided on October 22, 2022.