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

 
We decided that the Plan does not have to pay for the monitoring services provided on December 3, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the monitoring services. You say that the requirements for a referral were waived 
during the date of service and you would like the claim reprocessed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 monitoring services provided on December 3, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the sample to 
your laboratory, and you would like the claim to be covered. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 June 17, 2021, 
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from July 24, 2021 
to July 29, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you had COVID-19 so 
Medicare should cover this bill and you should not be responsible. 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 $395 
copayment for each Medicare-covered day, for days 1-4 and a $0 copayment for each additional day for 
inpatient stay.  
 You have been asked to pay a total of $1,580 for the inpatient stay ($395/day x 4 days = $1,580). The inpatient 
hospital stay 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 stay from July 24, 2021 to July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 23, 
2021. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you had the same procedure done a 
year ago and you didn't have a charge then. 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 $100 
copayment for other Medicare-covered diagnostic procedures and tests for the duplex scan.  
 
 You have been asked to pay a $100 for the duplex scan. A duplex scan 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 the duplex scan provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and urinalysis provided on  
December 10, 2021. 
 
You asked the Plan to pay for an office visit and urinalysis. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
service 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 an office visit and urinalysis provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on January 11, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory 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 it was 
determined these services were not urgent or emergent. 
 
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 Laboratory services provided on January 11, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on December 14, 
2021. 
 
You asked the Plan to waive the copayment for lab services. You say that the lab copayment should be 
included in your annual physical visit. 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 $20 
copayment per visit for laboratory tests.  
 
You have been asked to pay $20 for lab services. Lab services 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 
lab services provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on 
August 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says no prior authorization was made for this item 
provided by an OON provider. 
 
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 automatic external defibrillator 
(K0606) provided on August 19, 2021, by an out-of-network (OON) provider have been met. Specifically, no 
medical records were provided in this case. Without these medical records, we are unable to establish the 
medical necessity of the provided equipment. Therefore, we decided that the Plan does not have to pay for the 
automatic external defibrillator (K0606) provided on August 19, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 29, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health services. You say that you were unable to obtain a referral and it 
was medically necessary to treat the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 home health services provided on December 29, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement of the muscle and/or fascia provided on 
August 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement of the muscle and/or fascia. You say that even though you 
did not receive an authorization, you did receive the primary care physician order with an urgent request to 
treat this patient. The Plan denied your request. The Plan says after review, it was determined that this 
procedure code is not covered by the health plan because the provider is outside of the network of providers 
and there are no records of a prior authorization being obtained from the member's primary care physician prior 
to the services being rendered on August 5, 2021. 
 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 wound debridement of the muscle and/or fascia 
provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is needed for the enrollee to gain 
independence and to return to the prior level of functioning. The Plan denied your request. The Plan says SNF 
care is not medically necessary. The Plan says that the enrollee's needs can be met with nursing or therapy 
services provided at home or in a provider's office. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not 
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" in a SNF.  As a practical matter the enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 23, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says with the 
information provided, the Plan cannot determine how the member came to the servicing provider or whether 
the services are medically necessary. 
 
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 physician's services provided on 
August 23, 2021. have been met. Therefore, we decided that the Plan does not have to pay for physician's 
services provided on August 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel you should not have to pay 
for the ER visit. 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 $90 
copayment for each emergency care visit. 
 
You have been asked to pay $90 for the ER visit. An ER visit falls within the Emergency 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 the ER visit provided on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 22, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that that you were told the 
hospital stay would be completely covered due to a COVID-19 diagnosis. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment per day (per Medicare-covered stay) for days 1-7 which includes day of admission 
and day of discharge. After the 7th day, the plan pays 100% of covered expenses.   
The enrollee has been asked to pay a total of $1,575 for the inpatient hospital stay. An inpatient hospital stay 
falls within the Inpatient Hospital Care benefit 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 an inpatient hospital stay provided from September 22, 2021, to October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on November 4, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that you got this testing from a lab that does not 
accept insurance. You had to pay out-of-pocket and feel the Plan should reimburse you. You feel that you had 
all COVID symptoms, and this should be covered. The Plan denied your request. The Plan says records show 
that this was a planned test required in order for you to travel to Canada. Travel-related testing is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by third parties, such as 
Government agencies are not covered.  
 
We looked at the file and Medicare rules. The documentation provided shows that this testing was required by 
a Government agency to allow travel. This is not a covered indication under Medicare. Therefore, we decided 
that the Plan does not have to pay for the COVID-19 testing provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on October 1, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the radiology services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent 
or emergent. 
 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 radiology services provided on October 1, 
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Osteogenesis stimulator provided on 
December 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for Osteogenesis stimulator. You say that you don't agree with the 
amount billed. The Plan denied your request. The Plan says the members benefit states there is a 20% co-
insurance for Medicare covered items with a total rental or purchase price of $500.01 or more of the Medicare 
allowable rate per item. After review of case and members benefits, it has been determined that the claim was 
processed 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 20% 
coinsurance for Osteogenesis stimulator. The allowed amount of the Osteogenesis stimulator is $3,623.23, 
resulting in a coinsurance amount of $724.65. You have been asked to pay 20% coinsurance for Osteogenesis stimulator. Osteogenesis stimulator falls within 
the Durable medical equipment (DME) and related 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 coinsurance for Osteogenesis stimulator provided on December 30, 2021 by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on October 6, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that this care was medically necessary. 
The Plan denied your request. The Plan says this claim has denied correctly as a non-covered service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on October 6, 2021.