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

 
We decided that the Plan has to hold you harmless for the crown placed on May 7, 2020. 
 
You asked the Plan to hold you harmless for the crown. You say that this treatment was medically necessary 
and should be paid. The Plan denied your request. The Plan says that it was found that the long-term prognosis 
of a crown is poor so the denial of payment was correct. 
 
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 with the crown by a contract provider. The file does not show that the Plan provided notice 
that the crown would not be covered. Under Medicare rules, this means the crown is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold you harmless for the crown placed on May 7, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation services 
provided May 4, 2020 to May 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $295 
copayment per day, for days 1-6 and a $0 copayment for days 7 to 90, for in-network inpatient hospital care. 
Your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility 
type, including Inpatient Rehabilitation facilities. 
 
You have been asked to pay $885 ($295 copayment x 3 days) for the inpatient rehabilitation services provided. 
You initially received three days of inpatient rehabilitation services at another facility. You were then 
transferred and admitted directly to a different hospital for additional rehabilitation. According to the Plan 
contract, a copayment applies to the first six days of rehabilitation. The copayment charged in this case applies 
to the remaining three days of the first six days of care received. 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 acute inpatient rehabilitation services provided May 4, 2020 to May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on June 23, 
2020. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were told there was a $30 
copayment, which you paid. You say that you would have cancelled if you knew your copayment would be 
$280. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each Medicare-covered outpatient hospital service. 
 
You have been asked to pay a $250 copayment for the arthrocentesis. The arthrocentesis falls within the 
"Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
arthrocentesis provided on June 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
August 30, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had no choice in 
transportation, so you don't think you should have to pay the copayment. The Plan denied your request. The 
Plan says you were charged this copayment 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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance services. This copayment applies regardless 
of why you were transported. 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 services you 
received on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 
30, 2020, through February 4, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you do not agree with the 
copayment. 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 $380 
copayment per day for days 1 through 5 for in-network covered hospital care. 
 
You have been asked to pay a $1,900 copayment for the inpatient stay. ($380/day x 5 days = $1,900). The 
inpatient 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 stay provided from January 30, 2020, through February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the five Duplex scans you had on March 
2, 2020. 
 
You asked the Plan to waive the copayments for the five Duplex scans. You say that you did not know there 
would be five separate copayments applied-- you thought there would only be one copayment for all of the 
tests. The Plan denied your request. The Plan says you were charged these copayments 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 $150 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $150 copayment for each of the five Duplex scans. Your Evidence of Coverage 
clearly states that this copayment is owed for each individual test. 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 the five Duplex scans you had on March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
March 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that the services were not approved. 
 
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 ambulance service and ground mileage 
provided on March 6, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT image capture provided on June 29, 2020. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that the dentist needed this CT image 
to determine which tooth to pull. The Plan denied your request. The Plan says this is not a covered service 
under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT image capture provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided July 2, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says CPT code 71045 shares a Column I/Column II relationship with another 
code billed on the same date of service. 
 
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 71045 
has a bundled relationship with code 32555 and cannot be paid as billed. A modifier was not included to denote 
this as a separate service. 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 a 
chest x-ray (71045) provided July 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on July 7, 2020. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you had an eye doctor appointment 
and paid $25. 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 $25 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye. 
 
You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the "Vision care" 
benefit category. The records show that a medical eye exam and diagnostic imaging were provided during the 
visit. 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 eye exam provided on July 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 5, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you should not owe a second 
copayment because the ER visit was related to a previous visit two days earlier. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for eyeglasses provided on February 6, 2020. 
 
You asked the Plan to reimburse the enrollee for the eyeglasses. The Plan denied your request. The Plan says 
there is no coverage for eyewear under the Plan benefits except for post-cataract eyewear. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear.  
 
The services you asked the Plan to reimburse the enrollee for are considered routine eyewear. Therefore, we 
decided that the Plan does not have to reimburse the enrollee for eyeglasses provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
 
 
 
We find that HCPCS code G0483 is not supported in the medical record. Specifically, there is no valid 
physician order in this case. 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 drug testing services 
(HCPCS G0483) provided to the enrollee on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis (20610) and the office visit (99213) 
rendered by the out of network (OON) provider on August 27, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the arthrocentesis (20610) and the office visit (99213) rendered by the out of network 
(OON) provider on August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating 
provider on June 22, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you were told that this procedure would 
be covered. 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 $100 
copayment for outpatient surgery.  
 
You have been asked to pay a $100 copayment for a biopsy. The correct copayment has been applied to the 
surgery that was provided. A biopsy falls within the outpatient surgery 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 biopsy provided by a participating provider on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that home ventilators are covered when medically 
necessary. 
 
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 the home ventilator. Our reviewer says 
that the ventilator is not medically necessary. Our physician reviewer found certain BiPAP devices can provide 
the AVAPS-AE mode of support that has been ordered. Medicare does not cover a home ventilator when used 
as BiPAP. There is no evidence of failure of BiPAP in the home setting. A home ventilator is not medically 
necessary 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an x-ray and copayment for outpatient 
cardiac rehab services provided by a participating provider on April 27, 2020 to June 29, 2020. 
 
You asked the Plan to waive the coinsurance for an x-ray and copayment for outpatient cardiac rehab services. 
You say that you were not told that there would be a copayment for each visit. The Plan denied your request. 
The Plan says the correct coinsurance and 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 20% 
coinsurance outpatient diagnostic tests/in-network/diagnostic procedures/outpatient hospital and a $45 
copayment for outpatient diagnostic tests/in-network/diagnostic procedures/specialist's office. 
 
You have been asked to pay a 20% coinsurance of the allowed amount for an x-ray and a $45 copayment for an 
outpatient cardiac rehab services. The total allowed amount is $71.93. The amount you are being asked to pay 
for an x-ray is $14.39 ($71.93 x 20% = $14.39). The amount you are being asked to pay for cardiac rehab is 
$1,125 ($45 x 25 visits = $1,125). The total amount you are being asked to pay is $1,139.39. An x-ray falls 
within the outpatient diagnostic tests/in-network/diagnostic procedures/outpatient hospital benefit category and 
outpatient cardiac rehab services falls within the outpatient diagnostic tests/in-network/diagnostic 
procedures/specialist's office 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 x-ray 
and copayment for outpatient cardiac rehab services provided by a participating provider on April 27, 2020 to 
June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
June 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says dental services are only covered for in-network providers. 
 
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 Plan covers the services 
when the services are provided by a contracted provider. 
 
The services were not provided by a contracted provider. Based on this information, we decided that the Plan's 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for dental services provided by an out-of-network provider on June 9, 2020.