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

We decided that the Plan does not have to waive the copayment for the unna boot strapping provided on 
December 17, 2019, December 23, 2019, December 30, 2019 and January 6, 2020. 
 
You asked the Plan to waive the copayment for the unna boot strapping. You say that multiple copayments are 
a financial burden. The Plan denied your request. The Plan says the copayments 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 $100 
copayment for each Medicare-covered outpatient hospital service. 
 
You have been asked to pay a $100 copayment for each unna boot strapping. ($100/visit x 4 visits = $400). The 
unna boot strapping 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 the unna boot strapping provided on December 17, 2019, December 23, 2019, 
December 30, 2019 and January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (C-pap) device 
(E0601) rendered by the out of network (OON) provider on March 23, 2020. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no 
exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to 
pay for the continuous positive airway pressure (C-pap) device (E0601) rendered by the out of network (OON) 
provider on March 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (15771, 15772, 19328, 19340, 19366, & 
19371) provided February 4, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the CPT codes 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. 
 
We find that CPT codes 15771, 15772, 19328, 19340, 19366, & 19371 are not supported in the medical record. 
Specifically, the operative report does not describe each procedure as a separate and independent procedure. In 
cases where breast reconstructive procedures are combined, services should be reported by using CPT code 
19380. Based on this information, we decided that Medicare rules for coverage of the surgical services have not 
been met. Therefore, we decided that the Plan does not have to pay for surgical services (15771, 15772, 19328, 
19340, 19366, & 19371) provided February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (36415) provided on May 7, 
2020. 
 
You asked the Plan to waive the copayment for lab services. You say that this charge should be waived because 
the Plan is eliminating all out-of-pocket costs on in-network primary care visits. 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 $10 
copayment for lab services performed at an outpatient hospital or freestanding laboratory.  
 
You have been asked to pay a $10 copayment for lab services. Lab services fall within the "Outpatient 
diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan does not have to waive the 
copayment for lab services (36415) provided on May 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exams of the wrist (73110 x 2), x-ray exam of the 
lumbar spine (72110), x-ray exam of the thoracic spine (72072), and the x-ray exam of the cervical spine 
(72050) rendered by the out of network (OON) provider on February 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the x-ray exams of the wrist (73110 x 2), x-ray exam of the lumbar spine (72110),  
x-ray exam of the thoracic spine (72072), and the x-ray exam of the cervical spine (72050) rendered by the out 
of network (OON) provider on February 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the insertion of a gastrostomy tube 
provided on June 29, 2020. 
 
You asked the Plan to waive the copayment for the insertion of a gastrostomy tube. You say that you disagree 
with the charges because the surgery could not be completed. 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 $500 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The medical records show that you received the insertion of gastrostomy tube on June 29, 2020. Therefore, you 
are responsible to pay the $500 copayment.  
 
You have been asked to pay a $500 copayment for the insertion of a gastrostomy tube. The insertion of a 
gastrostomy tube falls within the outpatient surgery, including 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 
the insertion of a gastrostomy tube provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography provided on June 10, 
2020. 
 
You asked the Plan to waive the copayment for the CT angiography. You say that you were only charged $169 
for your previous scan. You say that there shouldn't be that much discrepancy in what you pay for the same 
service. The Plan denied your request. The Plan says the copayment 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 $250 
copayment for advanced imaging services.  
 
You have been asked to pay $243.90, which is less than the standard $250 copayment for the CT angiography. 
The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and 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. Therefore, we 
decided that the Plan does not have to waive the copayment for the CT angiography provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on March 19, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. You say that the Plan gave your provider incorrect 
information with regard to the network status of the hearing aid provider. The Plan denied your request. The 
Plan says your provider gave the Plan an I.D. number for a non-Medicare member and the Plan did not 
misquote the hearing aid benefit. 
 
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 you use the Plan's hearing aid provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not a network hearing aid provider with 
the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided June 4, 2020 to June 5, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that services were medically necessary. The Plan 
denied your request. The Plan says the claim was billed incorrectly. 
 
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 the outpatient services are not supported. Specifically, revenue code 637 is statutorily excluded 
when submitted without a HCPCS code. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for outpatient services provided June 4, 2020 to June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 24, 2020, to February 26, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never tested 
for Covid-19. You say that this was Covid-19 related and the copayment should be waived. The Plan denied 
your request. The Plan says the correct copayment has been 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 $345 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $345 copayment per day for days 1-2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $690 ($345 x 2 days = $690). The correct copayment has been applied to 
the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 24, 2020, to February 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room visit provided by a 
participating provider on July 10, 2020. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should only have a $45 
copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room visit. These services were provided in an 
emergency room facility; therefore, the correct copayment has been applied. Emergency room 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 emergency room 
visit provided by a participating provider on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit and urinalysis provided on 
February 19, 2020 by an OON provider. 
 
You asked the Plan to pay for the outpatient office visit and urinalysis. You say that a referral is not required 
for the procedure code billed. The Plan denied your request. The Plan says the services were rendered by an 
OON provider, the enrollee self-directed for care. The Plan also says that the enrollee's primary care physician 
did not refer the enrollee for services. 
 
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 outpatient office visit and urinalysis provided 
on February 19, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of tissue from wounds per session (97597) 
provided on January 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of tissue from wounds per session. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of tissue from wounds per session 
(97597) provided on January 10, 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 for 1 to 3 teeth per 
quadrant (D4342) provided on June 16, 2020. 
 
You asked the Plan to pay for the dental service. You say that you went in for a regular cleaning. You say that 
you had a deep cleaning in October and should not have needed another so soon. You say that the dentist advised 
they could lose their license if they did a regular cleaning. You also say that you do not believe that a deep 
cleaning was actually rendered. The Plan denied your request. The Plan says periodontal scaling and root 
planing is not listed as a covered service. 
 
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 for 1 to 3 teeth per quadrant (D4342) provided on June 16, 2020.  
 
Your complaint about the dentist is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission. 
 
You asked the Plan to pre-approve IRF admission. The Plan denied your request. The Plan says medical 
records were not submitted for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain records from the 
provider. The Plan made several attempted to obtain these records without response from the provider. Without 
medical records to determine medical necessity, it cannot be confirmed that Medicare coverage criteria have 
been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the microslide consultation provided on February 19, 2020 
by an OON provider. 
 
You asked the Plan to pay for the microslide consultation. You say that you did not obtain authorization for the 
services within the time limit. You also say that you would like authorization granted based on medical 
necessity. The Plan denied your request. The Plan says the service was rendered by a non-network provider. 
The Plan also says that the enrollee was referred by another non-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 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 microslide consultation provided on February 
19, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a formulary tier exception for a Freestyle Libre 14 Day 
Reader/Flash Monitoring System. 
 
You asked the Plan to pre-approve a formulary tier exception . You say that you would like reconsideration 
because this supply is medically necessary. The Plan denied your request. The Plan says payment for this 
service is covered under Medicare Part B so there is no possibility to make a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for the tier 
exception have not been met. Specifically, this supply is covered under Medicare Part B. Tier exceptions are 
specific to Medicare Part D. Therefore, we decided that the Plan does not have to pre-approve a formulary tier 
exception for a Freestyle Libre 14 Day Reader/Flash Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on May 5, 2020 
to May 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that the services are medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network providers. 
 
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 lumbar sacral orthosis (L0650) provided on 
May 5, 2020 to May 20, 2020 by an out of network (OON) provider.