Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261, V5267)  purchased 
on January 25, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261, V5267) purchased on January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on June 4, 2021 to June 7, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was updated.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 291. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that the documentation does not support the reporting of diagnosis code J96.21 - acute and chronic respiratory failure with hypoxia The admission documentation supports a normal pulse oximetry. The documentation more supports DRG 292 (Heart failure and shock with chronic condition). The enrollee did not require an increase oxygen above the baseline requirement of 3 liters during the stay

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on June 4, 2021 to June 7, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visits provided from 
January 27, 2023, to March 3, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visits. You say that you want to appeal 
these charges. 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 $750 deductible which applies to out-of-network specialist office 
visits. Your contract with the Plan also says that you pay a $0 copayment after meeting the deductible for out-
of-network specialist office visits. 
 
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 $750 deductible which applies to out-of-network specialist office visits. This cost sharing is a contractual 
obligation that had not been met at the time the specialist office visits was received on January 27, 2023, to 
March 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the specialist 
office visits provided from January 27, 2023, to March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 03, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. You depend on the facility to get the proper authorizations. 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 nursing facility visit 
provided on October 03, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network cataract procedure 
provided on February 2, 2023, and February 28, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network cataract procedure. You say that this was 
covered during covid but is now not covered. No one told you this and you feel you should not have to pay. 
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 40% 
coinsurance for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  The allowed amount of this procedure was $1,045.78, resulting in a $418.31 coinsurance. ($1,045.78 x 40% = 
$418.31). $418.31 x 2 = a $836.62 total coinsurance. 
 
You have been asked to pay a $836.62 total coinsurance for an out-of-network cataract procedure. This 
item/service falls within the Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges 
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 an out-of-network cataract 
procedure provided on February 2, 2023, and February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on November 10, 2021. 
 
You asked the Plan to pay for a portable chest x-ray. You say that this service was 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 a portable chest x-ray 
provided on November 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that your company has an exclusive contract 
with the facility. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the nursing facility care provided on January 18, 2023, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on November 22, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the imaging 
rendered in previous years was considered preventative and applied $0 cost share. 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 magnetic resonance image (MRI). 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 
magnetic resonance image (MRI) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy, and related services provided on 
February 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy, and related services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
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 
items/services 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 physical therapy, and related services provided 
on February 20, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 87150. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this code is not supported in the 
medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  
We asked our coder 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 procedure code 87150. Our reviewer says that this service is 
not supported as billed. Our reviewer found the medical record does not support reporting 12 units of 87150 as 
procedure code 87500 encompasses the cultures performed. The documentation does not support 87150 being 
separately done outside of the tests done 87500. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87150 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87150 billed for date of service December 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says procedure code J3490 is 
considered bundled to the minor surgery procedures provided on this date and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code J3490 has a status indicator of E on the Physician Fee Schedule and was submitted 
on a claim for services provided in an office/non-hospital setting. This means that procedure code J3490 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
billed for date of service May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services rendered 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 an office visit provided 
on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor provided 
on January 12, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that you never had to 
pay for this item before. 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 DME and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous glucose monitor. This item/service 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. The total you owe is $315 ($1,575 allowed amount 
x 20% = $315). Therefore, we decided that the Plan does not have to waive the coinsurance for the continuous 
glucose monitor provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac catheterization procedure 
provided on January 19, 2023. 
 
You asked the Plan to waive the copayment for the cardiac catheterization procedure. You say that you would 
like the procedure to be fully covered. 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 surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $200 copayment for the cardiac catheterization procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 cardiac catheterization procedure provided on January 
19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on 
February 14, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that this is a routine test you 
get every few years. 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 $35 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $35 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic tests, including ultrasounds 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 abdominal ultrasound provided on February 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 13, 2023. 
 
You asked the Plan to pay for home visit. 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 home visit provided on 
February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-keel foot. 
 
You asked the Plan to pre-approve a flex-keel foot. You say that the requested prosthesis is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested foot exceeds the 
enrollee's needs. 
 
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 a flex-keel foot. Our reviewer says that 
the request for a flex-keel foot is not considered medically reasonable and necessary in this case. Our physician reviewer found a flex-keel foot is its own base code describing an entire foot, not an addition to a flex-walk 
system, and coverage for it amounts to covering a second separate foot for this single prosthesis, given that a 
single K3 foot (L5981 & L5968) has already been authorized by the Plan. The reviewer found that two 
prosthetic feet for a given new socket would clearly exceed the enrollee's needs. The reviewer also found that 
there is no reasoning in the provided documentation as to why two feet would be needed for one prosthesis. 
Therefore, the reviewer found that the requested flex-keel foot is not medically reasonable or 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 a flex-keel foot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex-keel foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement procedure provided on 
December 30, 2022. 
 
You asked the Plan to waive the copayment for the debridement procedure. You say that you did not receive 
surgery services. 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 $335 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
You have been asked to pay a $335 copayment for the debridement procedure. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities 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 you received surgery 
services provided on December 30, 2022. However, since the allowed amount is less than the standard 
copayment, you only owe $317.21. Therefore, we decided that the Plan does not have to waive the copayment 
for the debridement procedure provided on December 30, 2022.