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

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you kept getting 
incorrect information from the nurses and the doctor had to call you to give you the proper answer to your 
question on January 13, 2022. 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 $30 
copayment for a specialist telehealth visit.  
 
 You have been asked to pay a $30 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the Physician/Practitioner Services, Including Doctors 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 January 13, 2022.  
 
Your complaint about the nurses giving you incorrect information is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted for a double lung transplant. The record indicates that the enrollee requires ongoing acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied.  The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an online instructional fitness class provided on 
February 17, 2021. 
 
You asked the Plan to reimburse you for an online instructional fitness class. The Plan denied your request. The 
Plan says the virtual reality game is not a covered benefit under your wellness allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the virtual reality game is not a 
covered benefit under your wellness allowance benefit. Therefore, we decided that the Plan does not have to 
reimburse you for an online instructional fitness class provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on 
January 18, 2022. 
 
You asked the Plan to pay for the testing. You say that this test is a Medicare-covered benefit. The Plan denied 
your request. The Plan says it cannot be determined how the enrollee came to the servicing provider, or 
whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the DecisionDX-SCC test was provided to the enrollee on January 18, 2022 and is being requested for 
coverage approval. However, the patient's records to support this request were not provided or sufficient to 
justify this request. There was no laboratory results/orders, medical notes from the ordering physician 
describing the reason for the testing, or other supportive information. Therefore, the DecisionDX-SCC will be 
considered not medically necessary based on the available documentation.   
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the DecisionDX-SCC test provided to the enrollee on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 2, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says you must 
see the Plan's hearing provider to use the hearing aid benefit. 
 
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. The Plan pays for 
hearing aids only when you see a Plan hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic Care provided on January 4, 2022 to January 
11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to appeal the denial of the claim 
and that the individual and referring provider are participating providers with Medicare. The Plan denied your 
request. The Plan says the provider is out-of-network and authorization is required prior to an out-of-network 
visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Chiropractic Care provided on January 4, 2022 to 
January 11, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on  
January 18, 2022, and January 19, 2022. 
 
You asked the Plan to waive the copayment for office visits. The Plan denied your request. The Plan says the 
claim 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 a $40 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits-Specialist Office.  
 
You have been asked to pay a $40 copayment for an office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits-Specialist Office 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 office visits provide on January 18, 2022, and January 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you thought this was a 
preventive colonoscopy and covered in full. You also say that if you would have known there would be a 
copayment you would not have had it done. 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 $400 
copayment for same-day outpatient surgery at an outpatient hospital.  
 
 The medical record shows you had a diagnostic colonoscopy on November 30, 2021. You have been asked to 
pay a $400 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the Outpatient 
Hospital 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 a diagnostic 
colonoscopy provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99442) provided on May 4, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network service was not pre-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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for physician services (99442) provided on May 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech therapy services rendered on November 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 92523 is not supported. 
 
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 92523 is evaluation of speech sound production (eg, 
articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and 
expression (eg, receptive and expressive language). 
 
We find that CPT code 92523 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the speech therapy services rendered on November 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health care. 
 
You asked the Plan to pre-approve the continuation of home health care. You say that the requested 
continuation of home health care is medically necessary. The Plan denied your request. The Plan says the 
requested continuation of home health care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 continuation of home health care. 
Our reviewer says that the requested continuation of home health care is not medically necessary. Our 
physician reviewer found the documentation doesnt support that the member requires additional skilled 
nursing services or skilled rehab services to provide treatment that is medically necessary. The member does 
not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the members condition, perform a maintenance program to maintain the members condition 
and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations.  The requested home health services are not medically 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 continuation of home health care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the continuation of home health care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that this was a routine eye 
exam and should have no 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 $40 
copayment for a diagnostic eye exam.  
 
The medical record shows you had a diagnostic eye exam on February 3, 2022. You have been asked to pay a 
$40 copayment for a diagnostic eye exam. A diagnostic eye exam falls within the Vision 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 a diagnostic eye exam provided on February 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on December 16, 2021. 
 
You asked the Plan to pay for the dermatology services. You say that you have the correct hospice modifiers on 
the claim. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for dermatology services provided on December 16, 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 enrollee's cancer could lead to death without any 
assistance. The Plan denied your request. The Plan says the therapy can be provided safetly in other settings, 
for example, as skilled nursing facility, home health services or home with outpatient therapy. 
 
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 stabilization surgery for lumbar spine fractures associated with metastatic cancer. 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 this 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 copayment for a comprehensive hearing test performed on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you were dissatisfied with the 
office and the test. 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 $40 
copayment for each visit for hearing services.  
 
You have been asked to pay $38.92, which is less than the $40 copayment for the hearing test. The hearing test 
falls within the Hearing 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 a 
comprehensive hearing test performed on January 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Esophagogastroduodenoscopy (EGD) 
[flexible, transoral; with directed submucosal injection(s), any substance] on January 19, 2022. 
 
You asked the Plan to waive the copayment for EGD. You say that the last time you had this procedure done it 
was a different amount. The Plan denied your request. The Plan says the cost-sharing amount you are being 
charged 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 $325 
copayment for each day of Medicare-covered observation services provided to you.   
 
 
 
 You have been asked to pay a $325 copayment for Esophagogastroduodenoscopy. 
Esophagogastroduodenoscopy falls within the in-network Medicare-covered services. You have a copayment 
for each Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges. The provider billed the plan in 
the amount of $1254.50. The allowed amount is $799.66. The plan paid $474.66. The allowed amount on this 
claim is $325. 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 Esophagogastroduodenoscopy (EGD) 
[flexible, transoral; with directed submucosal injection(s), any substance] on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections rendered on October 13, 2020 to October 14, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 these services was not filed until March 3, 2022. A valid waiver of liability 
(WOL) was not received until March 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 
injections rendered on October 13, 2020 to October 14, 2020.