Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on August 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer 
these services. The Plan says that prior authorization was not obtained. 
 
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 services provided on August 3, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99204) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that the OON 
provider is the only one available to treat your medical condition. The Plan denied your request. The Plan says 
multiple in-network providers are available to provide necessary medical 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office or other outpatient visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the tendon sheath incision at an out-of-
network provider on February 6, 2020. 
 
You asked the Plan to reduce the cost share for the tendon sheath incision. You say that the service was 
authorized. You say that you are requesting the claim be processed as in-network. The Plan denied your 
request. The Plan says the cost share applied correctly. 
 
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 your yearly out-of-network deductible is $500. This is the amount you have to 
pay out-of-pocket before we will pay our share for your covered out-of-network medical services. Until you 
have paid the deductible amount, you must pay the full cost for most of your out-of-network covered services. 
Your contract with the Plan also says that you must pay 40% coinsurance after the deductible per visit for 
outpatient surgery services. 
 
The item or service you asked the Plan to reduce the cost share for falls within the "Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that your yearly out-of-network 
deductible is $500. This cost sharing is a contractual obligation that had not been met at the time the tendon 
sheath incision was received on February 6, 2020. Therefore, $500 was applied to your deductible. 
  
 
 
Since the $500 deductible was met, you have also been asked to pay $393.23, which is 40% of the allowed 
amount for the tendon sheath incision. The allowed amount is $983.07 ($40% x $983.07 = $393.23). The 
records show that the provider is out-of-network. 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 cost share for 
the tendon sheath incision at an out-of-network provider on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the injections provided on February 26, 
2020 and office visits provided on March 4, 2020 and May 6, 2020. 
 
You asked the Plan to waive the cost share for the therapeutic injection, dihydroergotamine mesylate injection 
and office visits. You say that you believed you were seen by a primary care physician for the sick visits. You 
say that the visits were improperly coded as specialists instead of primary care visits. The Plan denied your 
request. The Plan says the cost share 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 20% 
coinsurance for each Medicare-covered Part B drug and a $45 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physician?s assistant or other 
non-physician health care professionals in a specialist?s office. 
 
You have been asked to pay $104.84 for the injections and office visits.  
 
Date of Service Service Allowed Amount Standard Cost 
Share 
Member Liability 
February 26, 2020 Therapeutic 
Injection 
$13.56 $45 $13.56 
February 26, 2020 Dihydroergotamine 
Mesylate Injection 
$0.12 20% $0.02 
February 26, 2020 Methylprednisolone 
Acetate Injection 
$6.29 20% $1.26 
March 4, 2020 Office Visit $103.26 $45 $45 
May 6, 2020 Office Visit $104.07 $45 $45 
TOTAL:    $104.84 
 
The dihydroergotamine mesylate injection and methylprednisolone acetate injection fall within the "Medicare 
Part B Prescription Drugs" benefit category. The therapeutic injection and office visits fall within the 
?Physician/Practitioner Services, Including Doctor?s Office Visits? benefit category. The records show that the 
services were provided by a specialist. 
 
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 share for the injections provided on February 26, 2020 and office visits 
provided on March 4, 2020 and May 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 30, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were told that you would not 
owe a copayment for the colonoscopy. 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 $300 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You received a colonoscopy on June 30, 2020 due to a positive Cologuard test. Therefore, the colonoscopy is 
considered a diagnostic, not preventative. Therefore, you are responsible to pay the $300 copayment.  
 
You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy 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 a colonoscopy provided on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 9, 2019. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on July 9, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Euflexxa injection provided on August 5, 2020. 
 
You asked the Plan to pay for the Euflexxa injection. You say that you were not told it was not covered. The 
Plan denied your request. The Plan says that that you did not meet medical necessity criteria for coverage of 
Euflexxa. 
 
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 Euflexxa injection by a contract provider. The file does not show that the Plan 
provided notice that the Euflexxa injection would not be covered. Under Medicare rules, this means the 
Euflexxa injection is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
Euflexxa injection provided on August 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on June 19, 2020. 
 
You asked the Plan to pay more for the complete maxillary denture and complete mandibular denture. You say 
that you were pre-qualified for the dentures to be covered. The Plan denied your request. The Plan says you are 
responsible for a $50 deductible, and a 50% coinsurance. 
 
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, you are also responsible for a $50 
deductible and 50% of the cost for complete dentures.  
 
Service Deductible Approved Amount 50% Coinsurance Member 
Liability 
Complete Upper Denture $50 $992 $496 $546 
Complete Lower Denture N/A $1,042 $521 $521 
TOTAL:    $1,067 
  
 
 
Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture (D5110) and 
complete mandibular denture (D5120) provided on June 19, 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 July 29, 2020, to August 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
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 $225 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days 1-4 for an inpatient hospital stay. The total 
amount you are being asked to pay is $900 ($225 x 4 days = $900). 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 July 29, 2020, to August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 14, 2019. 
 
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 November 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a CT scan provided on September 1, 2020. 
 
You asked the Plan to waive the deductible for a CT scan. You say that an X-ray was originally ordered not a 
CT scan and you feel the charges should be waived. The Plan denied your request. The Plan says the claims 
were processed correctly and the enrollee is being charged the correct amount. 
 
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 outpatient diagnostic tests and therapeutic 
services and supplies.  
 
The enrollee received a CT scan on September 1, 2020. The record shows that the enrollee had only paid 
$43.46 toward the $300 deductible prior to receiving the services. Therefore, the enrollee is responsible to pay 
the allowed amount of $106.49.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time a CT scan was 
received on September 1, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a 
CT scan provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on June 26, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that you were unaware you would be charged for an emergency transport or you wouldn't have pushed the life alert button. You say that you only live a mile from the hospital and shouldn't be charged $260.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 $260 copayment for Medicare-covered ambulance transport (one-way).You have been asked to pay a $260 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay at an IRF on March 30 to April 13, 
2020. 
 
You asked the Plan to waive the copayment for a stay at an IRF. You say that this charge should be processed 
as a skilled nursing facility charge. 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 $275 
copayment for each day of days 1-6 per admission for an in-network covered hospital stay.  
 
You have been asked to pay a $1,650 copayment, or a $275 copayment for each day of days 1-6, for a stay at 
an IRF. The facility where you stayed is an IRF and not a skilled nursing facility. A stay at an IRF 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 a stay at an 
IRF on March 30 to April 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip x-ray provided on August 4, 2020. 
 
You asked the Plan to waive the copayment for the hip x-ray. You say that this was your first follow up visit 
with your surgeon after a hip replacement. You say that the first visit after surgery should have no charge. 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 $30 
copayment for basic radiological services at an in-network specialist's office.  
 
You have been asked to pay a $30 copayment for the hip x-ray. The hip x-ray falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract 
which indicates a copayment would be waived for a service performed as a follow-up to 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 waive the copayment for the hip x-ray provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection and vitamin B12 
injection provided on June 1, 2020. 
 
You asked the Plan to waive the coinsurance for the denosumab injection and vitamin b12 injection. You say 
that you were told the shot was approved. You say that you wouldn't have received the shots if you knew you 
had to pay this amount. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a total of $232.53 for the denosumab injection and vitamin b12 injection.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
June 1, 2020 Denosumab 
Injection 
$1,160.40 20% $232.08 
June 1, 2020 Vitamin B12 
Injection 
$2.26 20% $0.45 
TOTAL:    $232.53 
 
 
  
 
 
The denosumab injection and vitamin b12 injection 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 denosumab injection and vitamin B12 
injection provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurobehavioral testing, initial 60 minutes (96116) 
neuropsychological testing, initial 60 minutes (96132) neuropsychological testing, each additional 60 minutes 
(96133) psychological or neuropsychological test administration and scoring by technician, two or more tests, 
any method; first 30 minutes (96138) provided June 11, 2019. 
 
You asked the Plan to pay for the neuropsychology evaluation. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT codes 96116, 96132, 96133, and 96138 is not supported in the medical record. 
Specifically, the medical records do not contain sufficient detail to support the billed charges. For CPT codes 
96116, 96132 and 96138 a documented duration of time is required to support this code. For CPT code 96133 
and 96138, a documented duration of time is required to support the code and the required preceding code was 
not supported, therefore, this service cannot be reimbursed separately. The plan made multiple attempts to 
obtain the needed additional information from the provider. Based on this information, we decided that 
 
 
Medicare rules for coverage of the neuropsychology evaluation have not been met. Therefore, we decided that 
the Plan does not have to pay for neurobehavioral testing, initial 60 minutes (96116) neuropsychological 
testing, initial 60 minutes (96132) neuropsychological testing, each additional 60 minutes (96133) 
psychological or neuropsychological test administration and scoring by technician, two or more tests, any 
method; first 30 minutes (96138) provided June 11, 2019.