Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 07, 2023, to 
April 18, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe that if you 
stayed over 6 days, everything would be paid in full. 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 $320 
copayment per day, days 1 to 6 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last 
inpatient day. For the first six days there is a $320 copayment. 6 x $320 = $1,920. Therefore, results in the total 
cost shairng amount of $1,920. 
 
You have been asked to pay a $320 copayment per day for inpatient hospital stay. 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 inpatient 
hospital stay on April 07, 2023, to April 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 provided on January 19, 2023. 
 
You asked the Plan to pay for procedure code 93970. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider must bill the enrollee's primary 
insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for procedure 
code 93970 until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for procedure code 93970 provided on January 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) visits provided on 
June 02, 2023, to June 12, 2023. 
 
You asked the Plan to waive the copayment for emergency room (ER) visits. You say that you were treated 
poorly and was incorrectly diagnosed. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for emergency room (ER) visits. This item/service 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. The total copayment you owe is $380  for the ER visits ($95 per visit x 4 visits = $380). Therefore, 
we decided that the Plan does not have to waive the copayment for emergency room (ER) visits provided on 
June 02, 2023, to June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on April 
18, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that the deductible should be 
waived 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network 
physician/practitioner services. Your contract with the Plan also says that you must pay a $50 copayment after 
meeting the deductible for out-of-network specialist office visits. 
 
 You have been asked to pay $177.88 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the physician/practitioner services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
the specialist office visit was received on April 18, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the specialist office visit provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided on 
February 28, 2023. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that there were two 
charges for this date of service, which you believe to be an error. 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 outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay 20% coinsurance for the radiation therapy services. This item/service falls within 
the outpatient diagnostic tests and therapeutic 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. The record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the radiation therapy services provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on April 17, 
2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 chiropractic 
manipulative treatment provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation services provided on January 01, 2023. 
 
You asked the Plan to pay for initial observation services. You say that these services were 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 initial observation 
services provided on January 01, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuropsychological testing provided on April 26, 2023, 
to April 28, 2023. 
 
You asked the Plan to pay for the neuropsychological testing. You say that you were referred for this service. 
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 the neuropsychological 
testing provided on April 26, 2023, to April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the medical records have been submitted to support 
medical necessity. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 an office visit provided on April 17, 2023, 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 the telehealth services provided on June 14, 
2023. 
 
You asked the Plan to waive the copayment for the telehealth services. You say that you disagree with the 
copayment. 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 $10 
copayment for physician/practitioner services, including doctors offic visits. 
 
You have been asked to pay a $10 copayment for the telehealth services. This item/service falls within the 
physician/practitioner services, including doctors offic 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 the telehealth services provided on June 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 01, 
2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. 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 $290 
copayment for outpatient hospital services. 
 
You have been asked to pay a $290 copayment for outpatient surgery. This item/service 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 outpatient 
surgery provided on June 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement lower limb prosthesis with a 
microprocessor-controlled knee. 
 
You asked the Plan to pre-approve the requested type of replacement prosthesis. You say that it is felt that this 
should be approved.  The Plan denied your request. The Plan says the requested prosthetic exceeds the 
enrollee's medical need. 
 
The Plan follows Medicare rules. Medicare rules say that replacement of an artificial limb may be covered 
when the criteria listed in the Medicare rules section are met. In addition, all services must be medically 
reasonable and necessary to be 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 the requested type of replacement 
prosthesis. Our reviewer says that the requested replacement prosthesis with a microprocessor-controlled knee 
is not medically reasonable and necessary.  Our physician reviewer found the documentation does not reveal 
that there has been a change in the physiological condition of the patient; an irreparable change in the condition 
of the device, or in a part of the device; or that the condition of the device, or the part of the device, requires 
repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, of 
the part being replaced. 
 
In addition, the physician documentation does not reveal medical reasons that support that this patient's 
activities cannot be met with a mechanical knee. Further the requested Ottobock C-leg has convenience 
features that exceed the patient's medical and functional needs such as MyModes and a companion Android 
app which would allow the patient to change modes quickly with Bluetooth technology for activities such as 
biking, golfing, walking or dancing. The patient's needs can be safely and effectively met with a less complex 
mechanical knee. 
 
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 requested type of replacement prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement lower limb prosthesis with a microprocessor-
controlled knee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health physical therapy visits 
(G0151). 
 
You asked the Plan to pre-approve home health services. You say that therapy is necessary for continued 
recuperation of a hip replacement surgery. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the health plans denial should be upheld. You do not have documented, home health 
(HH) physical therapy (PT) needs. You are functioning at a level commiserate with a lower level of care (i.e., 
home exercise program (HEP), outpatient therapy, layperson supervision). As such, the requested HH PT 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six (6) additional home health physical therapy visits (G0151).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for in-network knee injections provided from 
March 24, 2023, to April 13, 2023. 
 
You asked the Plan to waive the copayments for in-network knee injections. You say that this is a huge 
difference in price between an office visit and this. You cannot afford it. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You had four visits resulting in a $1,666.48 coinsurance ($414.46 + $414.46 + $418.78 + and $418.78 = 
$1,666.48) You have been asked to pay a $1,666.48 total coinsurance for in-network knee injections. This item/service 
falls within the Medicare Part B prescription drugs 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 in-network knee injections provided from March 24, 2023, to April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGX Comprehensive Complete Cancer Panel provided 
on March 14, 2023, and billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81209, and 81334. 
 
You asked the Plan to pay for the CGX Comprehensive Complete Cancer Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code.  

The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the CGX Comprehensive Complete Cancer 
Panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGX Comprehensive 
Complete Cancer Panel provided on March 14, 2023, and billed with codes 81162, 81201, 81292, 81295, 
81298, 81307, 81317, 81321, 81351, 81209, and 81334.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home laboratory kits provided on January 12, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for at-home laboratory kits. You say that no one told you this would be out of 
network or that it wouldnt be paid. 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 at-home laboratory kits 
provided on January 12, 2023, to February 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on March 13, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral, authorization, or notification is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on April 20, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the eye exam. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not 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 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 eye exam provided on April 20, 2023, by an 
OON provider.