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

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a non-
participating provider on August 26, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for an ambulance trip. The correct copayment has been applied 
to the services that were provided. An ambulance trip 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 for an ambulance trip provided by a non-participating provider 
on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and bone replacement graft for ridge 
preservation provided on October 7, 2020. 
You asked the Plan to pay for the extraction and bone replacement graft. You say that you would like to be 
refunded for these services. The Plan denied your request. The Plan says your $500.00 per year dental 
allowance has previously been applied to other dental services provided on July 7, 2020. 
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 Plan offers a $500 allowance every 
year for Non-Medicare covered preventive dental services and Non-Medicare covered comprehensive dental 
services combined. The contract says that you are responsible for any amount above the dental coverage limit. 
The record shows that you met the annual maximum benefit on July 7, 2020 and your annual maximum benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the extraction and bone 
replacement graft for ridge preservation provided on October 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on September 3, 2020.

You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says Medicare payment can only be made to Indian Health Service facilities when the proper billing rules are followed.

The Plan must follow Medicare rules. Medicare rules say that IHS facilities must bill using revenue code 0510 for outpatient services billed to Medicare. In this case, the correct revenue code was not used for IHS Medicare billing. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on September 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bilateral diagnostic digital breast tomosynthesis (77062). 
 
You asked the Plan to pay for the breast tomosynthesis billed with code 77062. The Plan denied your request. 
The Plan says the procedure code has a status code of "I" and is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate HCPCS/CPT code. The rules say that HCPCS/CPT codes 
with a status indicator of "I" are not recognized by Medicare and will not be paid. Medicare uses another code 
for reporting of, and payment for, these services. 
 
We find that payment for CPT code 77062 is not supported. Specifically, 77062 has a status indicator of "I" 
and will not be paid by Medicare. This service should be reported with a cod that is recognized by Medicare. 
Therefore, we decided that the Plan does not have to pay for a bilateral diagnostic digital breast tomosynthesis 
(77062).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for spinal manipulation. We decided that the Plan does not have to pay for 
a chiropractic office visit.  
 
You asked the Plan to pay for spinal manipulation. You say that you needed these services. The Plan says that 
chiropractic office visits are not covered, and the spinal manipulation was billed with an incorrect modifier.  
 
We decided that the Plan has to hold you harmless, apart from applicable cost-sharing, for spinal 
manipulation.  
 
The Plan follows Medicare rules. 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 provided spinal manipulation by a contract provider. The file does not show that the Plan provided 
notice that spinal manipulation would not be covered. Under Medicare rules, this means spinal manipulation is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for spinal 
manipulation.  
 
We also decided that the Plan does not have to pay for a chiropractic office visit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pre-approve non-emergency ambulance 
transportation. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the documentation shows that you are unable 
to ambulate. The documentation does not support that other means of transport (such as stretcher van, 
wheelchair van, taxi, private car, or other type of vehicle) are contraindicated. The documentation does not 
support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee brace (L1852) provided on July 27, 2020. 
 
You asked the Plan to pay for the knee brace. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid 
proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted does not clearly link 
the supplier's record to the delivery service record. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a knee brace (L1852) provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection. 
 
You asked the Plan to waive the coinsurance for the Denosumab injection. You say that you met your 
maximum out-of-pocket (MOOP) costs in March. The Plan denied your request. The Plan says you had $60 
remaining before you hit your MOOP costs when your claim processed on September 28, 2020. 
 
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 have an annual 
maximum out-of-pocket (MOOP) cost of $5,600 for 2020. In addition, you must pay 20% coinsurance for 
Medicare Part B drugs. 
 
You have been asked to pay $60 in coinsurance for the Denosumab injection. When this claim processed you 
had $60 remaining before you hit your maximum out-of-pocket costs for 2020. The Denosumab injection falls 
within the Medicare Part B prescription drug benefit category. $60 is less than or equal to the required 
coinsurance amount for Part B drugs. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by a non-participating 
oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says dental services provided by a non-participating oral 
surgeon are not covered under your supplemental dental 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. 
 
We looked at the file, the Plan's contract and Medicare rules. The dental services offered by the Plan are only 
covered when provided by a participating general dentist. Dental services provided by an oral surgeon are not 
covered. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by a 
non-participating oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the physician services provided on June 11, 2020. 
 
You asked the Plan to reimburse you for the physician services. You say that you have seen this doctor for 24 
years and do not want to go to a stranger. The Plan denied your request. The Plan says the Plan cannot pay a 
provider who is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the physician services provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on August 19, 
2020. 
 
You asked the Plan to waive the coinsurance for the Part B drug. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received Part B drugs on the date of service at issue in this appeal. The Plan 
says that the correct coinsurance has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B drugs on 
August 19, 2020. You have been asked to pay a 20% coinsurance for the Part B drug, totaling $15.68. The 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 the Part B drug provided on August 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary so you will 
be able to walk and not be a fall risk. The Plan denied your request. The Plan says your medical conditions are 
stable and do not require close physician supervision. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 pre-approve IRF care. Our reviewer says that you do 
not require the intensity of services provided at an IRF. Our physician reviewer found you are not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your needs can be 
met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 15, 2020 to September 18, 2020.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you felt like you had 
no other choice than to go to the inpatient rehabilitation. 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 $350 
copayment per day for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital for 
inpatient hospital care.  
 
You have been asked to pay a $350 copayment for each day of the inpatient hospital stay. ($350 x 3 days = 
$1,050). The 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 the inpatient hospital stay provided from September 15, 2020 to 
September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRA with CPT code 70544 provided on October 1, 
2020. 
 
You asked the Plan to pay for 70544. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan 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 have confirmed that code 70544 
has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the MRA with CPT code 70544 provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service (A0428) and mileage 
(A0425) provided on October 10, 2020. 
 
You asked the Plan to waive the copayment for ambulance and mileage. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was 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 $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance and mileage. This service 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 for ambulance service 
(A0428) and mileage (A0425) provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), and the unspecified preventive service (D1999) provided on October 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that you paid $4,798 for dental services in 2020 
since you had used up your $600 allowance. You say that the amount of $251 was for routine preventive care. 
You also say that you want to make sure it was handled correctly as it was preventive care. The Plan denied 
your request. The Plan says there is a $600 allowance for dental services every year. The Plan also says that the 
allowance has been exhausted. 
 
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 $600 allowance for dental services 
per year has been exhausted. The record shows that the Plan paid $336 for dental services that you received on 
July 21, 2020, and $264 for dental services that you received on September 22, 2020. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), 
and the unspecified preventive service (D1999) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 8, 
2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME 
item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the 
appropriate use of telehealth) and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-
face encounter included information supporting the enrollee was evaluated or treated for a condition that 
supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the 
written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided by a participating 
provider on September 1, 2020. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were told to go to the urgent 
care center or your PCP to have the stitches removed. You say that you thought that this visit was part of your 
initial visit. 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 $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for urgent care visit. Since an urgent care visit was provided, the 
correct copayment has been applied. 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 urgent care visit provided by a participating 
provider on September 1, 2020.