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

We decided that the Plan does not have to pay for the limited oral evaluation and implant removal provided on February 4, 2020.

You asked the Plan to pay for the limited oral evaluation and implant removal. You say that you needed surgery due to an infected tooth. You say that you were not informed the dentist had to be in the system to be reimbursed. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of 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. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and implant removal provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided to the enrollee on February 6, 
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 the enrollee's coverage requires an authorization for the reported service. 
 
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 pathology services provided to the enrollee on 
February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service your blood glucose 
levels had been high and you were showing signs of confusion. You say that your spouse was advised to call 
911 for assistance because you were in danger of becoming unconscious due to excessive insulin intake. When 
the emergency responders arrived, they checked your vitals and evaluated you. You say that the emergency 
responders stayed with you until they were certain that your blood glucose was not going to drop to dangerous 
levels. You asked the Plan to reconsider their decision and provide coverage because it was an emergency 
situation that could have been life threatening. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 22, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services received on January 18, 2020 and January 19, 
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 that there was no authorization for these services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services were provided by a contract provider. The file does not show that the Plan provided notice that the 
services would not be covered. Under Medicare rules, this means the services is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for home health services received on January 18, 2020 and 
January 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization services coded 37228 and 37226 provided on September 7, 2019.
You asked the Plan to pay for the revascularization services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 37228 and 37226 are not supported in the medical record. Specifically, the operative report did not include documentation of an open or percutaneous endovascular revascularization of a unilateral tibial or peroneal artery. Therefore, code 37228 cannot be verified. The operative report did not include documentation of an open or percutaneous endovascular revascularization of a unilateral femoral or popliteal artery(s), with transluminal stent placement(s), including angioplasty within the same vessel. Therefore, code 37226 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization services coded 37228 and 37226 provided on September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on March 31, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 
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 nurse practitioner services provided on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair, detachable arms, desk or full length, swing away detachable footrests (E1140) provided to the enrollee from March 18, 2020 through March 28, 2020.
You asked the Plan to pay for the DME. You say that the enrollee has walking problems and falls, due to dementia. The Plan denied your request. The Plan says a wheelchair may be appropriate for the enrollee, however, the Medicare required information listed below is needed to consider coverage. The Plan states to have the enrollee's doctor submit a request with the information to consider coverage of a wheelchair.
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 DME have not been met. The wheelchair code sent to us (E1140) is not a Medicare approved code for a wheelchair. The code (E1140) is used for maintenance and service of an item already approved and paid by Medicare. The appeal is for the same unapproved code. Also, Medicare requires information about the enrollee's walking ability and the enrollee's ability to use a wheelchair where the enrollee lives. None of the information was originally received. Therefore, we decided that the Plan does not have to pay for wheelchair, detachable arms, desk or full length, swing away detachable footrests (E1140) provided to the enrollee from March 18, 2020 through March 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a cardiovascular stress test and 
diagnostic nuclear medicine procedures provided from January 8, 2020 to February 18, 2020. 
 
You asked the Plan to pay for the cardiovascular stress test and diagnostic nuclear medicine procedures. The 
Plan denied your request. The Plan says in order for medical services to be covered under this plan they must 
be received from providers contracted with the Plan. The only exceptions to this are in cases of urgent or 
emergently-needed care; if the medical care required cannot be provided by contracted, in-network providers 
and the Plan has given prior authorization for such care; and kidney dialysis services obtained at a Medicare-
certified dialysis facility when you are temporarily outside the plan's service area. Point-of-Service coverage is 
available at 20% of the Medicare allowed amount. 
 
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 contract with the Plan says that Point-of-Service coverage is 
available at 20% of the Medicare allowed amount. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. The Plan has a POS coverage benefit available at 20% of the Medicare allowed amount. We 
found no exception that would require the Plan to pay an additional amount for these services. Therefore, we 
decided that the Plan does not have to pay an additional amount for a cardiovascular stress test and diagnostic 
nuclear medicine procedures provided from January 8, 2020 to February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation and x-ray provided on January 14, 2020. 
 
You asked the Plan to pay for the oral evaluation and x-ray. You say that you were told after your visit that you 
couldn't use your insurance. You say that you would have waited if you knew you weren't covered. The Plan 
denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation and x-ray provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from May 30, 2019 to August 
20, 2019. 
 
You asked the Plan to pay for the services provided. You say that you have been seeing the provider since 
2017. The Plan denied your request. The Plan says payment for services cannot be issued for a provider who 
does not participate with 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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the medical services provided from May 30, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth specialist visit (G2012) 
provided on April 28, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this copayment has been applied 
correctly to the service 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 $35 
copayment for each physician specialist visit and telehealth service including consultation, diagnosis, and 
treatment by a physician or practitioner. 
 
You have been asked to pay a $14.33 copayment for the telehealth specialist visit provided. The Plan contract 
states you must pay a $35 copayment for each physician specialist visit and telehealth service including 
consultation, diagnosis, and treatment by a physician or practitioner. The allowable charge for this service was 
$14.33, which is less than the applicable copayment. 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 telehealth specialist visit (G2012) provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 12, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you live in a rural area and this is 
the only location you can go to. You state that you never had an issue in the past. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for laboratory tests provided in an outpatient hospital facility.  
 
You received laboratory tests on March 12, 2020 at an outpatient hospital facility. Therefore, you are 
responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for laboratory tests. Laboratory tests fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for laboratory tests provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on 
January 2, 2020. 
 
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that the in-network 
information was withheld. The Plan denied your request. The Plan says out-of-network dental services are not 
covered benefits. 
 
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, out-of-network services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis 
and periodic oral evaluation provided on January 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided by a 
participating provider on May 12, 2020 to May 14, 2020. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you shouldn't have to pay for 
this because it was a continuation of care. The Plan denied your request. The Plan says the correct copayments 
have 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 $60 
copayment for outpatient diagnostic tests/radiation therapy.  
 
You have been asked to pay a $60 copayment for each radiation therapy. The total amount you are being asked 
to pay is $180 ($60 x 3 sessions = $180). Radiation therapy falls within the outpatient diagnostic tests/radiation 
therapy 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 radiation therapy provided 
by a participating provider on May 12, 2020 to May 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on 
February 18, 2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because this claim was filed timely. The Plan denied your request. The Plan says this claim was not filed timely 
and no good cause was found to account for timely filing. 
 
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 emergency department visit was not filed until February 26, 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 an emergency department visit (99285) provided 
on February 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 4, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit (99283) on 
April 19, 2020. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that you should be 
charged the copayment for urgent care because there is no urgent care facility near you. 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 $50 
copayment for each emergency room visit in the U.S. 
 
You have been asked to pay a $50 copayment for an emergency department visit. An emergency department 
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 copayment for 
an emergency department visit (99283) on April 19, 2020.  
 
Your complaint about the lack of an urgent care facility in your vicinity is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services (10060, 99213) provided on August 28, 
2019 to November 5, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON podiatry services. You say that you were told this provider took your 
insurance. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 podiatry services (10060, 99213) provided on 
August 28, 2019 to November 5, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (71046) provided February 14, 2020. 
 
You asked the Plan to pay for x-ray. You say that the services were medically necessary. The Plan denied your 
request. The Plan says the services must be billed to the primary payer first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary payer. As the secondary insurer, the Plan cannot be held responsible 
for x-ray until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for portable x-ray services (71046) provided February 14, 2020.