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

 
We decided that the Plan does not have to waive the copayment for the specialist office visit was provided by a 
network physician on January 21, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider was only in 
the room for one minute, and told you there was nothing that could be done for your rash. You say the provider 
should not be paid. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment per visit to a specialist.  
 
 You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office visits benefit category. The medical 
record shows services were rendered during the office visit. 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 was provided by a network physician on January 21, 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 do not want to see another 
specialist as you are in the middle of care. You also say you are scheduled to have a procedure with the 
requested provider on April 12, 2022, for the first surgery and on April 19, 2021, for second surgery. The Plan 
denied your request. The Plan says an authorization was approved for you to have an ophthalmology 
consultation with an in-network provider. The Plan also says that the requested provider does not accept your 
current plan, and are not willing to see you with the requested rates. 
 
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 right hip surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve right hip surgery. You say that based upon your current physical condition, 
continuing and excruciating pain, your inability to lose the additional 30 pounds, your loss of mobility, and 
further based upon the recommendations of the specialist and the support of your Plan providers, you want the 
denial reversed. The Plan denied your request. The Plan says they will not refer you to a non-network provider 
for right hips surgery, and you will be offered a second opinion with a Plan orthopedic surgeon. 
 
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 
right hip surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral sleep apnea appliance and an office visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an oral sleep apnea appliance and an office visit. You say that you want to 
see this provider for the sleep apnea appliance, and he is the closest one to you. The Plan denied your request. 
The Plan says it is not medically necessary to have this service out-of-network, and there are providers in your 
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 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 
an oral sleep apnea appliance and an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
November 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were not given a 
choice of which transport provider to use. You say that you believe you are not responsible for the cost share. 
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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $250 copayment for the ambulance transport. Ambulance transport falls within 
the Ambulance 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 the 
ambulance transport provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the laboratory services provided on February 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven additional units for injection(s), anesthetic agent(s) 
and/or steroid; brachial plexus (64415) provided to the enrollee on June 17, 2021. 
 
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the additional 7 units will remain denied as the medical 
records submitted do not indicate that multiple separate services were performed. 
 
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 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
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 services. Our reviewer says that the additional units at 
issue in this case were not supported by the medical records. Our reviewer found the procedure report does not 
support seven additional units for this procedure. The procedure report describes a peripheral nerve block 
given. In this case, seven additional units are not supported.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for seven additional units for injection(s), anesthetic agent(s) and/or steroid; brachial plexus 
(64415) provided to the enrollee on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) of the cervical spine. You say that you 
were told that your condition seems to present as a pinched nerve and carpal tunnel syndrome in your right 
hand, and you have had this problem since August 5, 2020, and it has gotten progressively worse. You also say 
you need this MRI to confirm a diagnosis so that you can receive the proper and necessary treatment. The Plan 
denied your request. The Plan says the member must use network providers to get medical care and services 
when there are network providers available, there are available in-network facilities, and the in-network 
facilities were contacted and can provide the requested service. 
 
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 magnetic resonance imaging (MRI) of the cervical spine 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 pay for inpatient post-stabilization services provided to the enrollee 
from March 28, 2020, to March 12, 2020.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was not proper and prompt notification after post-stabilization. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 supported by the documentation. Our physician reviewer found that no 
medical records were submitted with the supporting documentation. Based on the submitted documentation, the 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service. and there is no clinical documentation submitted so there is no 
decision regarding what day and time the patient was stable to transfer by ambulance to an in-network hospital. 
 
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 inpatient post-stabilization services provided to the enrollee from March 28, 2020, to March 12, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. The appropriate treatment is bilevel positive airway pressure (bipap), with or without average 
volume-assured pressure support (AVAPS) mode.  Medicare does not pay for a ventilator when used as bipap. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 21, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the insurance should pay the adjusted 
payment due for the ultrasound. The Plan denied your request. The Plan says copayment 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
  You have been asked to pay $106.85, which is less than the standard $150 copayment for an ultrasound. 
Ultrasounds 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 the ultrasound provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled nursing facility (SNF) care provided on January 10, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled nursing facility (SNF) care. You say that you would like to appeal the 
denial of the 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 Skilled nursing facility (SNF) care provided on 
January 10, 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 Skilled nursing facility (SNF) care provided from January 
13, 2022 to January 18, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled nursing facility (SNF) care. You say that you would like to appeal the 
denial of the 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 Skilled nursing facility (SNF) care provided from 
January 13, 2022 to January 18, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455, 81479, 81301, and 81194) 
provided on December 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will 
be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. 
 
We find that the remaining denied CPT codes are not supported in the medical record. Specifically, the testing 
at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (81455, 81479, 81301, and 81194) provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) on 
February 8, 2022. 
 
You asked the Plan to waive the copayment for Magnetic resonance imaging (MRI). You say that you were 
unaware that there was a copay. 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 a $275 
copayment for Magnetic resonance imaging (MRI). The claim processed with a financial responsibility to the 
member of $245 as the allowance was less than the $275 copayment. 
 
You have been asked to pay a $275 copayment for Magnetic resonance imaging (MRI). Magnetic resonance 
imaging (MRI) falls 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 Magnetic resonance imaging (MRI) on 
February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tendon sheath synovectomy performed on 
March 4, 2022. 
 
You asked the Plan to waive the copayment for the synovectomy. You say that you feel the copayment is 
incorrect. 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 $350 
copayment for each outpatient hospital visit for surgery or other services.  
 
You have been asked to pay a $350 copayment for the synovectomy. The synovectomy 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 tendon sheath 
synovectomy performed on March 4, 2022.