Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (CPT code 88305) provided on 
September 22, 2021. 
 
You asked the Plan to pay for the surgical pathology. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the surgical pathology have not been met. The provider did not bill 
as required by Medicare coding regulations. Using the billed CLIA number 45D1090651 as search criteria 
returned results as no CLIA Laboratories were found with that number. Search criteria using the CLIA Facility 
Name, Inform Diagnostics Inc, has a CLIA Identification Number: 45D2255567, with Address: 11511 Spoonwood Path, San Antonio, TX, 78245, however this does not match the billing CLIA Identification 
Number and address and a CLIA certificate has not been issued for this facility. Per the above guidelines CLIA 
requires all facilities that perform tests derived from materials taken from patients for purposes of providing 
information for the diagnosis, prevention, or treatment of any disease obtain a CLIA certificate and meet CLIA 
regulatory requirements. Therefore, as a surgical pathology CPT code 88305 was billed without CLIA 
certification we find the Medicare rule for reimbursement of this September 22, 2021, claim has not been met. 
If the provider determines that a billing error occurred during the initial submission of the denied claim, the 
plan will accept a submission of a corrected claim to consider services for payment. You can find the above 
Medicare guidelines on the Medicare web site, https://www.cms.gov and https://qcor.cms.gov. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology (CPT code 88305) provided on September 
22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a duplex scan (ultrasound) of extremity 
veins provided on January 20, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you were informed your 
copayment would only be $50. 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 $250 
copayment for each diagnostic radiology service other than CT scans.  
 
You have been asked to pay $95, which is less than the $250 copayment for the ultrasound. The ultrasound 
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 reduce the copayment for a duplex scan (ultrasound) of extremity veins provided on 
January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that this is not for convince, you cannot get in or out 
of your house as you have stairs at both the front and back doors. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aid repair provided on January 4, 2022. 
 
You asked the Plan to reimburse you for hearing aid repair. You say that you were told this service would be 
covered. The Plan denied your request. The Plan says hearing aid repair is not a covered benefit under your 
Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that there is no coverage for hearing aid repairs. 
Therefore, we decided that the Plan does not have to reimburse you for hearing aid repair provided on  
January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
April 13, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you were not informed that 
telehealth was no longer covered. 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 $35 
copayment for each specialist telemedicine visit.  
 
You have been asked to pay a $35 copayment for the telehealth visit. The telehealth 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 telehealth visit provided on April 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided from 
January 18, 2022, to January 20, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the cost is too 
much to afford. 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 $90 
copayment for each one-way ambulance trip.  
 
The file shows that you had one trip on January 18, 2022, and two on January 20, 2022, for a total of three 
trips. Therefore, you have been asked to pay a $90 copayment for each ambulance transportation, for a total of 
$270. The ambulance transportation 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 copayments for ambulance transportation provided from January 18, 2022, to 
January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for total electric hospital bed (CPT code E0265) 
purchased on October 7, 2021. 
 
You asked the Plan to reimburse for the total electric hospital bed. You say that you ordered the bed from this 
provider because they were the only provider you could find that would supply the bed. The Plan denied your 
request. The Plan says the bed is not covered by Medicare and the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that 
a total electric hospital bed (E0265) is not covered; the height adjustment feature is a convenience feature. 
Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not 
have to reimburse for total electric hospital bed (CPT code E0265) purchased on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a peri=prosthetic hip fracture after a fall. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided by an out-
of-network (OON) provider on February 9, 2022. 
 
You asked the Plan to waive the coinsurance for the OON office visit. You say that you were not informed that 
the provider was out-of-network. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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% 
coinsurance for out-of-network specialist services.  
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$81.45, which is 50% of the allowed amount for the OON office visit ($162.91 allowed amount x 50% 
coinsurance = $81.45). The OON office 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 coinsurance for a specialist 
office visit provided by an out-of-network (OON) provider on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on December 23, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 
23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 4, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you have no money 
and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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 
ambulance transportation provided on February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for lumbar-sacral orthosis (CPT code L0650) and the knee orthoses (CPT 
code L1833 x2) provided on April 28, 2021. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice 
from the billing provider to indicate the specific supplies. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthoses have been met. The documentation submitted did 
include an itemized shipping/billing invoice from the billing provider to indicate the specific supplies. 
Therefore, we decided that the Plan has to pay for lumbar-sacral orthosis (CPT code L0650) and the knee 
orthoses (CPT code L1833 x2) provided on April 28, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's care and the criteria for coverage have been met. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the services needed could be provided in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel that you 
were balance billed. 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 $300 
copayment for each one-way ambulance trip.  
 
The file shows that the Plan contacted the provider and verified that the provider billed in error and will 
reimburse the overpayment. However, you are responsible for a $300 copayment for the ambulance 
transportation. The ambulance transportation 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 ambulance transportation provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments for wound care services provided 
from January 25, 2021, to March 1, 2021. 
 
You asked the Plan to waive or reduce the copayments for the wound care. You say that you feel all the 
provider did was look at the wound and wrap it. 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 $295 
copayment for each outpatient hospital visit. 
 
 
 
 
 
 Wound Care Dates of Service Copayment per EOC Actual Charges 
January 25, 2021 $295 $203.50 
February 8, 2021 $295 $203.50 
February 15, 2021 $295 $203.50 
February 22, 2021 $295 $203.50 
March 1, 2021 $295 $203.50 
March 15, 2021 $295 $203.50 
Total: $1,770.00 $1,221.00 
 
You have been asked to pay a total of $1,221 for the wound care. The wound care 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 or reduce the copayments for wound care services provided from 
January 25, 2021, to March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on January 25, 2022. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says your vision benefit 
only covers routine eyewear when obtained from a participating provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by any participating vision care provider. 
 
 We looked at the file and the Plan's rules. The file shows that the eyewear was not provided by a participating 
vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear 
have not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on 
January 25, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency services provided from June 13, 2021, through June 18, 
2021. 
 
You asked the Plan to pay for the emergency services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that payment is not allowed for this service because this service included in another 
service provided to the enrollee at the same time by same provider; therefore, the member is not responsible for 
payment. 
 
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. 
 
Review of the file shows that the plan did not substantiate their denial. There is no evidence the Plan paid a 
primary procedure. Therefore, we decided that the Plan has to pay for the emergency services provided from 
June 13, 2021, through June 18, 2021.  
 
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.