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

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. You say your doctor was sick and you were not sure 
when the office would reopen. The Plan denied your request. The Plan says non-emergent, non-urgent services 
with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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's services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided 
on March 4, 2020. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree 
with the facility charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 $145 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay the allowed amount of $118.03, which is less than the $145 copayment for an 
outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient hospital facility visit provided on March 4, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided from July 26, 2019 to
August 2, 2019.
You asked the Plan to pay for behavioral health services. You say that you have submitted claims correctly
with the approved revenue codes per the Plan's contract. The Plan denied your request. The Plan says this
type of bill does not support the services rendered/identify the appropriate place of treatment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that Medicare recognizes CMHCs but only for furnishing partial hospitalization services.
CMHCs bill for partial hospitalization services under bill type 76X.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
payment of the behavioral health services have not been met. Specifically, the record shows that the services
were not billed under bill type 76X. The services are therefore not payable as billed. Therefore, we decided that
the Plan does not have to pay for behavioral health services provided from July 26, 2019 to August 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided February 7, 
2020 to February 11, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 per admission for Inpatient Hospital Care.  
 
You have been asked to pay a $200 copayment for the inpatient hospital admission. 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 care provided February 7, 2020 to February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 
15, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition or medical records signed by 
the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
80307 and G0483 provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit rendered on February 19, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were for diabetes and 
should have no copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Medicare-covered specialist visit.  
 
Review of the file shows that you received services from an advanced registered nurse practitioner (ARNP). 
The services were not performed by an endocrinology physician. You have been asked to pay a $40 copayment 
for these services. These services fall within the Medicare-covered specialist visit 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 office visit rendered on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by a 
non-network provider. 
 
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 services were rendered by a non-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on February 11, 
2020 by a non-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (HCPCS G0482) provided to the enrollee on 
December 5, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Healthcare Common Procedure Coding System (HCPCS) code G0482 remains 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 HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-
21 drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewers says that the 
services at issue in this were supported by the medical records. Our physician reviewer found the laboratory 
submitted a valid/signed physician laboratory requisition form and lab results. The review has determined that 
the records support the denied codes. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (HCPCS G0482) provided to the enrollee on December 5, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 1, 2019. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing 
why the testing services provided were medically necessary. In this case, there were insufficient records 
provided to show the results of this testing would be used to determine a diagnosis or determine a treatment 
strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for 
screening purposes. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have 
to pay for genetic testing provided to the enrollee on July 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you would like to appeal the bill for the 
ambulance services. You say that the ambulance came to your home and only checked your vitals. You stated 
that you were not transported anywhere because you were fine. You asked the Plan to reconsider their decision. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $200 copayment charged for ambulance transport 
provided on February 20, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe you should have to pay this 
copayment. The Plan denied your request. The Plan says this copayment was charged based on the service 
provided and the Plan contract agreement. 
 
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 $200 
copayment for ambulance transport one way.  
 
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 $200 copayment charged for ambulance transport provided on February 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on March 26, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration because this 
monitoring is part of the stroke care. The Plan denied your request. The Plan says only one interpretation of an 
electrocardiogram report is allowed per date of service when performed in the Emergency Room. 
 
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 find that CPT code 93010 is not supported in the record. Specifically, the record indicates that one unit of 
CPT code 93010 was paid for this date of service. This claim was not submitted with a modifier to indicate a 
questionable finding requiring a repeat procedure. Based on this information, we decided that Medicare rules 
for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to 
pay for an electrocardiogram (93010) provided on March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) provided on March 5, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
You exhausted your benefit frequency limit, because you had this same service performed on August 21, 2019.
Your EOC states that for comprehensive exam (for a new patient, or an established patient after 3 or more
years of inactivity from dental treatment) - one (1) procedure every three (3) plan years. Therefore, we decided
that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150)
provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 20, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that the cost should be waived since you did not 
receive the service from the provider and you received a prescription from your primary care physician (PCP) 
for the antibiotics just to help reduce the infection. The Plan denied your request. The Plan says when you 
contacted the plan prior to the services rendered you were advised that this provider is not contracted with your 
plan. 
 
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. 
 
Review of the file show that you received the dental services provided on May 20, 2020 by an out-of-network 
provider. Your EOC states, services are covered with providers in the Plan network only. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide 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 dental services provided on May 20, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 11, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the documentation does not support the services billed. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided 
on October 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the 
enrollee from December 20, 2019 through December 28, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believed the enrollee's 
copay would be $720 and not $1,800. The Plan denied your request. The Plan says the claim was processed 
accordingly with the enrollee's 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that the enrollee was admitted on December 20, 2019 and discharged on December 
28, 2019. The enrollee was asked to pay a $360 copayment per day from December 20, 2019 through 
December 24, 2019, days 1-5 of their inpatient stay. There were no copayment charges from December 25, 
2019, day 6 of their inpatient hospital care until the enrollee's day of discharge December 28, 2019. Per the 
enrollee's contract there is a $360 copayment per day required for days 1-5.  This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for inpatient hospital care provided to the enrollee from December 20, 2019 
through December 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for health club membership purchased from January 1, 
2019 through December 31, 2019. 
 
You asked the Plan to reimburse for the health club membership. You say that you are requesting 
reimbursement of services rendered. The Plan denied your request. The Plan says you did not submit the 
reimbursement within 31 days. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Review of the file show that you purchased the health club membership from January 1, 2019 through 
December 31, 2019. You did not submit the reimbursement within 31 days. Your EOC states that member 
requests for reimbursement of qualified membership dues may be submitted monthly but must be received no 
later than 31 days following the end of plan year. Therefore, we decided that the Plan does not have to 
reimburse for health club membership purchased from January 1, 2019 through December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided by a non-Plan provider on March 4, 
2020. 
 
You asked the Plan to pay for hearing aids. You say that you did not know that you had to use a specific 
provider and are dissatisfied with the hearing aids you received. The Plan denied your request. The Plan says 
the denial of payment for these hearing aids is correct, because hearing aids are only covered by the Plan when 
obtained from the Plan's routine hearing 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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from the Plan's routine hearing provider.  
 
We looked at the file and the Plan's rules. These hearing aids were not provided by the Plan's routine hearing 
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 pay for hearing aids provided by a non-Plan provider 
on March 4, 2020.