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

 
We decided that the Plan does not have to pay for an eye refraction provided on March 19, 2020. 
 
You asked the Plan to pay for eye refraction. You say that you do not think you should be penalized for this 
refraction because the doctor is not a routine vision care provider. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because this eye refraction is not covered when performed as 
part of a medical eye examination. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided as part of a routine eye examination by a Plan routine 
vision care provider. 
 
We looked at the file and the Plan's rules. This eye refraction was performed as part of a medical eye 
examination, not a routine eye exam, therefore it is not covered by the Plan's supplemental vision benefits. 
Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye refraction provided on March 19, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to hold you harmless for hospital services provided on December 27, 2019 
through December 31, 2019. 
 
You asked the Plan to hold you harmless for the hospital services. You say that you would like reconsideration 
because these were emergency services. The Plan denied your request. The Plan did not address the concerns at 
issue in your appeal. 
 
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. 
 
You were referred for the hospital services by a contract provider. The file does not show that the Plan 
provided notice that the hospital services would not be covered. Under Medicare rules, this means the hospital 
services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for 
hospital services provided on December 27, 2019 through December 31, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on April 22, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. The Plan denied your request. The Plan 
says the benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and an 
additional intraoral periapical x-ray on April 22, 2020, the first intraoral periapical x-ray was covered by the 
Plan, and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to 
pay for the additional intraoral periapical x-ray provided on April 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
April 30, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that your mother was 
transferred and admitted to a second hospital. You say the emergency room copayment from the first hospital 
should be waived. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $90 copayment for each Medicare-covered emergency room visit.  
 
The enrollee has been asked to pay a $90 copayment for the emergency room visit. The emergency room visit 
falls within the Emergency 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 emergency room visit provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient visit provided by a 
participating provider on January 2, 2020. 
 
You asked the Plan to waive the deductible for an outpatient visit. You say that you were unsatisfied with the 
service you received. The Plan denied your request. The Plan says the correct deductible amount has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible for physician/practitioner services/in-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/in-network. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $300 deductible for in-network services. The total amount you are being asked to pay is 
$54.63. This cost sharing is a contractual obligation that had not been met at the time an outpatient visit was 
received on January 2, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
outpatient visit provided by a participating provider on January 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit (99285, 71046) 
provided February 24, 2020. 
 
You asked the Plan to waive the copayments for the emergency room visit. 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The 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 copayments for an 
emergency room visit (99285, 71046) provided February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IRF care from March 5, 2020 through 
March 12, 2020. 
 
You asked the Plan to waive the copayment for IRF care. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 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 you were admitted on March 5, 2020 and discharged on March 12, 2020. You 
were asked to pay a $325 copayment per day from March 5, 2020 through March 9, 2020, days 1-5 of your 
inpatient stay. There were no copayment charges from March 10, 2020, day 6 of your inpatient hospital care 
until your day of discharge March 12, 2020. Per your contract there is a $325 copayment per day required for 
days 1-5. 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 IRF care from March 5, 2020 through March 
12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the shower/tub remodel services rendered on
January 23, 2020.
You asked the Plan to reimburse you for these services. You say that you assumed the services would be
covered. The Plan denied your request. The Plan says the services do not serve a purpose that is primarily
medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to reimburse you for the shower/tub remodel services rendered on January
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 3, 
2020. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you do not feel you should have 
to pay this additional amount because this was not an urgent care. The Plan denied your request. The Plan says 
the copayment amount you are being charged is correct. 
 
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 $35 
copayment for urgent care visit. This visit was provided by an urgent care facility, therefore the urgent care 
copayment applies to this claim. 
 
You have been asked to pay $35 copayment for urgent care visit. urgent care visit falls 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 copayment for an urgent care visit 
provided on March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 30, 
2019 through January 21, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Original Medicare. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on October 30, 2019 through January 21, 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 
December 26, 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 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 December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three amalgams provided on February 7, 2019. 
 
You asked the Plan to pay for the amalgams. You say that you received dental services, but did not know there 
was a time limit to file. The Plan denied your request. The Plan says you received dental services on February 
7, 2019. The Plan did not receive your request for reimbursement until February 12, 2020, or 370 days after the 
date of service. 
 
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 amalgams was not filed until February 12, 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 three amalgams provided on February 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided by a non-
participating provider on March 17, 2020 to April 12, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you do not agree with these 
charges. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for physician/practitioner services/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible for out-of-network services. The total amount you are being asked to 
pay is $304.18 ($159.99 + $144.19 = $304.18).  This cost sharing is a contractual obligation that had not been 
met at the time an office visit was received on March 17, 2020 to April 12, 2020. Therefore, we decided that 
the Plan does not have to waive the deductible for an office visit provided by a non-participating provider on 
March 17, 2020 to April 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable gaseous oxygen system and oxygen concentrator 
rental from October 1, 2019 to March 1, 2020. 
 
You asked the Plan to pay for the portable gaseous oxygen system and oxygen concentrator rental. You say that 
the Plan should pay this claim. The Plan denied your request. The Plan says a recent oximetry test, recent 
prescription, or updates on usage was not provided. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The rules say that oxygen is coverable when medically necessary for patients 
with significant hypoxemia who meet certain blood gas evidence requirements. 
 
We looked at the file and Medicare rules. There is no documentation of recent studies or physician visit. Based 
on this information, we decided that Medicare rules for recertification of the portable gaseous oxygen system 
and oxygen concentrator rental have not been met. Therefore, we decided that the Plan does not have to pay for 
the portable gaseous oxygen system and oxygen concentrator rental from October 1, 2019 to March 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided to the enrollee on 
March 2, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this is a duplicate claim line because it has been previously processed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. This is duplicate claim because it 
has been previously processed under another claim for the exact same code. Both providers are within the same 
group have the same primary specialty.  The documentation submitted does not support either codes as being 
performed for billed date of service March 2, 2020. Therefore, we decided that the Plan does not have to pay 
for subsequent hospital care (99232) provided to the enrollee on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection of venous blood by venipuncture services 
provided on October 18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the collection of venous blood by venipuncture services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are 
not a covered benefit. 
 
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 collection of venous blood by venipuncture 
services provided on October 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of daratumumab provided on 
October 10, 2019. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you are appealing. The Plan denied 
your request. The Plan says the coinsurance amount you are being charged is correct. 
 
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 Part B drug. The allowed amount of this drug is $6,849.70, resulting in a coinsurance 
obligation of $1,369.94. 
 
You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls 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 an injection of 
daratumumab provided on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on March 10, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you 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 $20 
copayment for X-rays.  
 
You have been asked to pay a $20 copayment for an X-ray. An X-ray 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 
an X-ray provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on 
December 30, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the documentation indicates services are not necessary for 
treatment of the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the 
case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the 
enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be 
required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The 
documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this 
case, as there is no documentation of a physical examination of the wrist. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for wrist hand orthosis (L3916) provided to the enrollee on December 30, 2019.