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

 We decided that the Plan does not have to waive the copayments for urgently needed services provided on 
March 29, 2020 and May 2, 2020. 
 
You asked the Plan to waive the copayments for urgently needed services. You say that you disagree with the 
charges because you went to a walk-in clinic not an urgent care 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 $40 
copayment for urgently needed services.  
 
The medical records show that you received urgently needed services on March 29, 2020. Therefore, you are 
responsible to pay the $40 copayment.  
 
The medical records show that you received urgently needed services on May 2, 2020. Therefore, you are 
responsible to pay the $40 copayment. 
 
The total amount you owe is: $80.  
 
You have been asked to pay the total copayment amount of $80 for urgently needed services. Urgently needed 
services fall within the urgently needed 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 
copayments for urgently needed services provided on March 29, 2020 and May 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care, subsequent hospital care, and 
hospital discharge day management provided from January 21, 2020 to January 29, 2020. 
 
You asked the Plan to pay for the inpatient hospital care, subsequent hospital care, and hospital discharge day 
management. You say that this enrollee was sent to hospice after this emergency hospital admission. You also 
say that this claim should be paid in full, and not made the responsibility of the enrollee or the physician. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 17, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
care, subsequent hospital care, and hospital discharge day management provided from January 21, 2020 to 
January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 6, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were never charged in the 
past and disagree with the 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 $40 
copayment for specialist office visits.  
 
You have been asked to pay the allowed amount of $21.98, which is less than the $40 copayment for a 
specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on 
March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 6, 2020. 
 
You asked the Plan to pay for out of network physician services. You say that this claim should be paid. 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 services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab work provided on December 18, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. 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. The Plan says that 
the member's primary care physician did not refer these 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 lab work provided on December 18, 2019 by an 
out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for wrist x-rays (73130) provided on December 26, 2019. 
 
You asked the Plan to pay for the wrist x-rays. You say that you would like reconsideration because this 
member received multiple exams on the same date of service. The Plan denied your request. The Plan says the 
documentation supports one unit of CPT codes 73130 LT and 73130 RT, which were previously approved and 
paid. 
 
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 73130-26-LT and 73131-26-RT is not supported in the record. Specifically, the record 
indicates that CPT codes 73130 Lt and 73130 RT were previously approved and paid. The documentation 
submitted does not support that additional units of these services were rendered on this date of service. Based 
on this information, we decided that Medicare rules for coverage of the wrist x-rays have not been met. 
Therefore, we decided that the Plan does not have to pay for wrist x-rays (73130) provided on December 26, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the CT scan provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the 
CT scan copayment because this is a second CT scan since the first scan was poor. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $200 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear 
scans and PET scan, per date of service.  
 
You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The record shows you received a CT 
scan on March 16, 2020. 
 
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 scan provided on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care provided to the enrollee 
from February 1, 2020, to February 7, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says the claim processed 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $310 copayment per day for the first six days of each inpatient admission.  
 
Review of the file shows the enrollee was provided five days of inpatient care. The enrollee has been asked to 
pay a $310 copayment per day for these services, totaling $1,550. The services fall within the inpatient hospital 
care benefit category. 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 the inpatient care 
provided to the enrollee from February 1, 2020, to February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the implantable pump pain infusions 
provided from January 4, 2020 to February 29, 2020. 
 
You asked the Plan to waive the coinsurance for the implantable pump pain infusions. You say that this service 
was always 100% covered. You were told your coverage would not change. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for Medicare Part B drugs at a pharmacy.  
 
You have been asked to pay a total of $285 for the implantable pump pain infusions. The implantable pump 
pain infusions fall within the Medicare Part B prescription drugs benefit category.
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the implantable pump pain infusions provided from 
January 4, 2020 to February 29, 2020. 
 
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact 
the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ultrasounds provided on February 28, 
2020. 
 
You asked the Plan to waive the copayments for ultrasounds. You say that you disagree with the charges 
because you feel that the services were preventative. 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 $110 
copayment for each radiological diagnostic service. 
 
You received two ultrasounds on February 28, 2020. Therefore, you are responsible to pay the total allowed 
amount of $213.66, which is less than the total copayment amount.   
 
You have been asked to pay $213.66 for ultrasounds. Ultrasounds 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 copayments for 
ultrasounds provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for resin-based composite - two surfaces, tooth 3 (D2392) resin-
based composite - three surfaces, posterior, teeth 4, 5 (D2393) resin-three surfaces, anterior, tooth 6 (D2332) 
provided February 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went to this facility because you had 
services performed by them in 2019. The office called prior to services being rendered to verify billing info and 
eligibility. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-
network provider. 
 
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. The health plan contract 
specifically says if you receive care from an out of network dental provider you must pay for your own care. 
 
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 when rendered by an out of network provider. Therefore, we decided 
that the Plan does not have to pay for resin-based composite - two surfaces, tooth 3 (D2392) resin-based 
composite - three surfaces, posterior, teeth 4, 5 (D2393) resin-three surfaces, anterior, tooth 6 (D2332) 
provided February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for the wound care and the physical therapy 
visit provided from February 14, 2020 to February 25, 2020. 
 
You asked the Plan to reduce the copayments for the wound care and the physical therapy visit. You say that 
you are being charged as an outpatient surgery when there was no surgery. You say you saw a physical 
therapist and were told you would only have a $30 copayment. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $250 
copayment for each Medicare-covered in-network outpatient hospital facility visit and a $30 copayment for 
Medicare-covered in-network physical therapy visits.  
 
You have been asked to pay a total of $720.46 for the wound care and the physical therapy visit. The wound 
care falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical center benefit category. The physical therapy visit falls within the Outpatient 
rehabilitation services benefit category. The record shows that wound care is considered a surgical procedure. 

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 reduce the copayments for the wound care and the physical therapy visit provided 
from February 14, 2020 to February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility services provided on January 23, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility services. The Plan denied your request. The Plan 
says the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 
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 subsequent nursing facility services provided on January 23, 
2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab work provided on December 16, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. 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. The Plan says that 
the member's primary care physician did not refer these 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 lab work provided on December 16, 2019 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 medical services provided to the enrollee by an out-of-network provider 
on January 4, 2020.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the Guardant360 testing provided on January 13, 2020. 
 
You asked the Plan to pay for the testing. You say that the services were ordered by an in-network provider. 
The Plan denied your request. The Plan says that the services were not authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Guardant360 testing by a contracted provider. The file does not show that the 
plan provided notice that the testing would not be covered. Under Medicare rules, this means the testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the Guardant360 testing 
provided on January 13, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on August 15, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 28, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on August 15, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for  the bone replacement graft for ridge preservation (D7953) 
provided January 3, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that the deemed this procedure surgical and 
therefore it needs to be paid by your health insurance. The Plan denied your request. The Plan says this oral 
surgical procedure is regarded as a medical 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. Bone replacement grafts and 
specialized implant surgical techniques, including radiographic/surgical implant index is listed under 
Exclusions and Limitations, on page 8 of the Summary of Dental Plan Benefits.  
 
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 bone 
replacement graft for ridge preservation (D7953) provided January 3, 2020.