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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 29, 2022, to April 1, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not have a 
private room during your stay. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for a Medicare-covered stay at 
a network hospital. 
 You have been asked to pay a $300 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $900 ($300 copayment x 3 days = $900). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from March 29, 2022, to April 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 98941) and 
the office visits (99212, 99213) provided from March 15, 2021, through January 20, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an out-of-network provider. Additionally, chiropractic office visits are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
  
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements made with them. Additionally, a chiropractic office 
visit is not a covered benefit by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay 
for the chiropractic manipulative treatments (98940, 98941) and the office visits (99212, 99213) provided from  
March 15, 2021, through January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram service provided on January 27, 2023. 
 
You asked the Plan to pay for an electrocardiogram service. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
service provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 21, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the enrollee has a biopsy 
proven to be non-melanoma skin cancer. The infiltrative basal cell carcinoma of his left medial distal pretibial 
area will require the treatment benefits received with the FDA approved technology, Image-Guided Superficial 
Radiation Therapy. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. There is not enough evidence that this type of radiation therapy guidance is needed 
or effective for the enrollee's skin cancer. 
 
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 pre-approve ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general) is not necessary.  The decision is 
unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote EKG monitoring services 
provided on January 9, 2023. 
 
You asked the Plan to waive the copayment for the remote EKG monitoring services. You say that you are 
being charged twice for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network specialist services.  
 
You have been asked to pay a $30 copayment for the remote EKG monitoring services provided by the 
provider. You have also been asked to pay a $30 copayment for the remote EKG monitoring services provided by the facility. These items/services fall within the outpatient diagnostic tests and therapeutic services benefit 
category. You have been asked to pay a total of $60 ($30 copayment + $30 copayment = $60). 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 remote EKG monitoring services provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on 
June 29, 2022. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were told you 
would have a $0 copayment for this equipment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the osteogenesis stimulator. This item/service falls within the 
durable medical equipment 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. The total you owe is $952 ($4,760  x 20% coinsurance = $952). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator 
provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on January 31, 2023. 
 
You asked the Plan to pay for wound care. You say that you believe the services are medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail disorder provided on December 02, 2022. 
 
You asked the Plan to pay for nail disorder. You say that you are requesting a reconsideration of the denied 
charges. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nail disorder provided 
on December 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from September 28, 
2022, to October 5, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you should only have to pay one 
inpatient copayment of $1,750 and should not have to pay the additional copayment for an IRF visit. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 per 
day for days 1 to 5 and $0 for additional days for inpatient hospital stay.  
 
 
  You have been asked to pay $1,750 for an IRF stay ($350 per day x 5 days = $1,750). This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an IRF stay provided from September 28, 2022, to October 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you disagree 
with the copayment applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $131.33, which is less than the standard $200 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductibles for the specialist office visits provided from 
December 21, 2022, to February 8, 2023. 
 
You asked the Plan to waive the deductibles for the specialist office visits. You say that you did not know 
services were rendered by an out-of-network provider. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network 
physician/practitioner services, including doctor's office visits. Your contract with the Plan also says that there 
is 20% coinsurance after the deductible has been met for each out-of-network specialist visit. 
 
The enrollee has been asked to pay $89.01 towards the deductible for the specialist office visit provided on 
December 21, 2022. The enrollee has also been asked to pay $87.59 towards the deductible for each specialist 
office visit provided on January 16, 2023, and February 8, 2023. The enrollee has been asked to pay a total of 
$264.19 ($89.01 deductible + $87.59 deductible + $87.59 deductible = $264.19). The items or services you 
asked the Plan to waive the deductibles for fall within the physician/practitioner services, including doctor's 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $500 deductible which applies to physician/practitioner services, including doctor's office visits. This 
cost sharing is a contractual obligation that had not been met at the time the specialist office visits was received 
on December 21, 2022, to February 8, 2023. Therefore, we decided that the Plan does not have to waive the 
deductibles for the specialist office visits provided from December 21, 2022, to February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on December 11, 2022. 
 
You asked the Plan to pay for observation care. You say that you are requesting the submitted documentation 
be reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for observation care 
provided on December 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implant (D6010). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of an implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) provided on 
December 22, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that your crown came off and only glue 
was left to put the crown back on it. You also say that your plan allows $200.00 for dental and should cover the 
$172.00. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a re-
cement or re-bond crown (D2920) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) and 
colonoscopy (43235, 45378). 
 
You asked the Plan to pre-approve an EGD and colonoscopy. 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 endoscopy is a technique in which a long flexible 
tube-like instrument is inserted into the body orally or rectally, permitting visual inspection of the 
gastrointestinal tract. 
 
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 an EGD and colonoscopy. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the EGD and colonoscopy at issue in this case meet all of Medicare's 
NCD criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not document persistence of reflux symptoms on the Pepcid therapy; records do not report dysphagia, 
odynophagia, bleeding, anemia or vomiting. Provided records do not document the results of stool studies. 
Although the enrollee is due for a follow-up screening colonoscopy (code G0121), this is not the procedure that 
has been requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD and colonoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) and colonoscopy (43235, 45378).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you do not 
think the copayment charged is correct and you are not paying that amount. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 
computed tomography (CT) scan provided on March 24, 2022.