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

 
We decided that the Plan does not have to pay for out of network chiropractic care from February 20, 2020 to 
March 20, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network chiropractic care from February 20, 2020 to 
March 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a hernia repair surgery (49505) provided 
on December 5, 2019. 
 
You asked the Plan to waive the coinsurance for a hernia repair surgery. You say that patients with Original 
Medicare did not have a copayment at this facility. The Plan denied your request. The Plan says this processed 
correctly according to your contract. 
 
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-covered outpatient surgery.  
 
You have been asked to pay a $569.34 coinsurance for a hernia repair surgery ($2,846.70 allowed amount x 
20% = $569.34). 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 a hernia repair surgery (49505) 
provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, post and core for crown, and 
emergency palliative care services provided on April 13, 2020 and April 27, 2020. 
 
You asked the Plan to pay for the endodontic therapy, post and core for crown, and emergency palliative care 
services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan 
says the services received are 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 Plan?s 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 the 
endodontic therapy, post and core for crown, and emergency palliative care services provided on April 13, 
2020 and April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture provided on December 17, 2019. 
 
You asked the Plan to pay for the upper partial denture. You say that your denture was delivered on February 
26, 2020. You say that your new plan covers dentures up to 25%. The Plan denied your request. The Plan says 
the 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 Plan?s 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 the upper 
partial denture provided on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on March 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 71046. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 16, 2019. 
 
You asked the Plan to pay for the genetic 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and application of autologous blood 
concentrate product (D7921) provided on April 8, 2020. 
 
You asked the Plan to pay for the collection and application of autologous blood concentrate product. You say 
that you were required to get these services as an emergency situation. The Plan denied your request. The Plan 
says this service is not a covered benefit 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 Plan?s 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 the 
collection and application of autologous blood concentrate product (D7921) provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 22, 2020. 
 
You asked the Plan to pay for the physician's services. 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 June 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on March 9, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because 
an attending physician told you to go to the facility. 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 $80 
copayment for emergency care.  
 
You have been asked to pay a $80 copayment for an ER visit. An ER visit 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. 
Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on March 
9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric  evaluation provided on March 19, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for an OON psychiatric  evaluation. You say that this was a medically necessary 
service provided in good faith. The Plan denied your request. The Plan says this 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 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 psychiatric  evaluation provided on March 19, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
January 29, 2020. 
 
You asked the Plan to pay for the scaling and planing. The Plan denied your request. The Plan says this service 
is not a covered benefit 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 Plan's 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 the 
periodontal scaling and root planing (D4341) provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482 and 80307) provided to the enrollee on 
November 12, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says there is insufficient physician order and documentation to support the codes billed. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided to the enrollee. 
 
 Therefore, we decided that the Plan does not have to pay for lab services (G0482 and 80307) provided to the 
enrollee on November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 24, 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 referring provider 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 March 24, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes 
L3916, L1971. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. There is no delivery ticket or itemized invoice. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the durable medical equipment (DME) defined by codes L3916, L1971.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 9, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the medical services provided from 
February 21, 2020 to March 3, 2020. 
 
You asked the Plan to waive the copayments for the medical services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received these services on the dates of service at issue in this appeal. The Plan 
says that the correct cost share has applied per your contract with the Plan. 
 
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 services obtained from a specialist, a $20 copayment for non-radiological diagnostic services, 
and a $150 copayment for each radiological diagnostic service.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services 
obtained from a specialist on February 21, 2020. These services included an office visit and an ECG. You have 
been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the 
Physician/Practitioner services benefit category. You have been asked to pay a $15.87 copayment for the ECG, 
which is less than the contracted $20 copayment amount. The ECG falls within the Outpatient diagnostic tests 
benefit category.  
 
The file also shows that you received an echocardiography on February 26, 2020. You have been asked to pay 
a $150 copayment for the echocardiography. The echocardiography falls within the Outpatient diagnostic tests 
benefit category. 
 
The file finally shows that you received an MPI SPECT and cardiovascular stress test on March 3, 2020. You 
have been asked to pay a $150 copayment for the MPI SPECT as this is considered a radiological diagnostic 
service and a $20 copayment for the cardiovascular stress test as this is considered a non-radiological 
diagnostic test. The MPI SPECT and cardiovascular stress test fall within the Outpatient diagnostic tests benefit 
category. 
 
This means that you have been asked to pay the correct amounts 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 the medical services provided from February 21, 2020 to 
March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the colonoscopy, endoscopy, lab services, 
and office visits you had from March 9, 2020 through June 16, 2020. 
 
You asked the Plan to waive the cost sharing for the medical services. You say that you are not satisfied with 
the amounts you have to pay out of pocket. You say that you know that you needed the procedures, but you 
don't think you should have to pay this much. The Plan denied your request. The Plan says you were charged 
this cost sharing appropriately. 
 
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 a $225 
copayment for outpatient surgery, a $20 copayment for lab services, and a $45 copayment for visits with a 
specialist. 
 
Records show that you had a combined endoscopy/colonoscopy on June 2, 2020. You were charged a $225 
copayment for this service. A combined endoscopy/colonoscopy is an outpatient surgical service. According to 
your Evidence of Coverage, you are responsible for a $225 copayment for outpatient surgery services, so you 
were charged this amount correctly. You also had lab services on that same date of service. You were charged a 
$20 copayment for these lab services. Your Evidence of Coverage says that you are responsible for a $20 
copayment for labs per day per provider, so you were charged this copayment correctly. In addition, you had 
office visits on March 9, 2020 and June 16, 2020 with a gastroenterologist. A gastroenterologist is a specialist.  
Your Evidence of Coverage says that you are responsible for a $45 copayment for each visit with a specialist, 
so you were charged these copayments correctly.  
 
 
All of these copayment responsibilities total $335. 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 cost sharing for 
the colonoscopy, endoscopy, lab services, and office visits you had from March 9, 2020 through June 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 13, 
2019 to December 17, 2019. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not feel that you owe the 
amount for these self-administered drugs. The Plan denied your request. The Plan says these drugs are self-
administered, and are not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from December 13, 2019 to December 17, 2019.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis (L1971), a plastic foot (L3170) and 
shoulder elbow wrist hand orthosis (L3960) provided on March 24, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because this equipment was medically necessary. The Plan denied your request. The Plan says the 
documentation submitted does not include an itemized shipping/billing invoice to indicate the specific supplies 
or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
includes a delivery ticket for a different date of service. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for ankle foot orthosis (L1971), a plastic foot (L3170) and shoulder elbow wrist hand orthosis (L3960) 
provided on March 24, 2020.