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

We decided that the Plan does not have to pay for transportation services provided to the enrollee on June 25, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not filed timely. The request and the waiver of liability are both dated 
beyond the one-year limit to file. 
 
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 this service was not filed until June 26, 2020 and the waiver of liability was 
not signed until July 24, 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 transportation services 
provided to the enrollee on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for scooter. You say that this scooter helps you get around in daily functions inside 
and outside of the home. The Plan denied your request. The Plan says the denial of payment for this device is 
correct, because this provider is out-of-network with the Plan and 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 the medical services provided by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the drug testing 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 covered. 
 
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 drug testing services provided on April 27, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on November 5, 2019. 
 
You asked the Plan to pay for the extraction. You say that you paid $117 out of pocket for your tooth to be 
pulled, and were told once you have the receipt you could submit it for reimbursement. The Plan denied your 
request. The Plan says the claim has been processed correctly according to your dental benefit. The Plan also 
says that no contacts were made to the Plan prior to the date of service to verify your plan benefits for dental 
services. 
 
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 responsible for a 50% 
coinsurance for tooth extractions. Therefore, we decided that the Plan does not have to pay for the extraction 
provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99203) chiropractic manipulative 
treatment (98942, 98941) provided July 18, 2020 to August 6, 2020. 
 
You asked the Plan to pay for the chiropractic visits. You say that you are appealing the decision where your 
chiropractor was not covered. You are disabled and on a fixed income. The Plan denied your request. The Plan 
says this the correct copayment was applied and office visits are not covered when billed by a chiropractor. 
 
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. Therefore the office visit is not covered per the plan 
benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for each in-network Medicare covered chiropractic visit.  
 
You have been asked to pay $210 for the chiropractic services. The chiropractic visits fall within the 
chiropractic 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 pay for outpatient office visit (99203) 
chiropractic manipulative treatment (98942, 98941) provided July 18, 2020 to August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and portable gaseous oxygen 
(E1390, E0431) provided on November 16, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator and portable gaseous oxygen. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 oxygen concentrator and portable gaseous 
oxygen (E1390, E0431) provided on November 16, 2019, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an eye exam (92004) performed on 
February 19, 2020. 
 
You asked the Plan to waive the deductible for an eye exam. You say that a representative of the Plan told you 
this service would be completely covered and you wouldn't have to pay anything. The Plan denied your 
request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $198 deductible for Medicare-covered eye exams.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Vision Care" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 
deductible for Medicare-covered eye exams. This cost sharing is a contractual obligation that had not been met 
at the time an eye exam was received on February 19, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for an eye exam (92004) performed on February 19, 2020.  
 
Your complaint about receiving erroneous or ambiguous information about your cost-sharing responsibilities 
from a representative of the Plan 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
July 24, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you have a handicap 
and should not be charged. 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 $40 
copayment for each basic imaging service.  
 
You have been asked to pay a $40 copayment for the diagnostic mammogram. The diagnostic mammogram 
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records 
show that a diagnostic mammogram was ordered and performed. 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 diagnostic mammogram provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 20, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the 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 physician services provided 
to the enrollee on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests provided on August 18, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory tests. You say that there is no copayment if the 
tests are performed as part of an office visit. 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 $10 for 
Medicare-covered laboratory tests. 
 
You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests fall within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests 
are considered a separate service. 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 laboratory tests 
provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 11, 2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
 
 
likewise noncovered. This claim was billed with an invalid or missing modifier. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services provided on August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) provided 
from September 1, 2019, to September 14, 2019. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you believed that the stay at the 
SNF was covered. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $0 
copayment per day (days 1-20) and a $172 copayment per day (days 21-100) for skilled nursing facility care.  
 
You have been asked to pay a total copayment of $2064 for the SNF stay. The copayment for the first two days 
of SNF care is $0 because these were days 19 and 20 of SNF care. This leaves 12 remaining days with a 
copayment of $172 per day. Therefore, the Plan is charging the correct total copayment of $2064 ($172 x 12). 
The services provided fall within the skilled nursing facility 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 skilled nursing facility (SNF) provided from September 1, 2019, to September 
14, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed  (99306) provided June 17, 2020. 
 
You asked the Plan to pay for the transthoracic echocardiography. You say that please see attached medical 
records. The Plan denied your request. The Plan says the records do not support the billed 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, the CPT Code Manual definition of code 93306-26-76 is Echocardiography, transthoracic, real-
time with image documentation (2D), includes M-mode recording, when performed. 
 
We find that CPT code 93306-26-76 is not supported in the medical record. Specifically, there is insufficient 
documentation to corroborate if Medicare coverage criteria has been met or whether the services are medically 
necessary. Non-contracted providers are required to furnish necessary information to the health plan when 
requested. The records show that the plan had made multiple attempts to obtain the needed additional 
information without success. Based on this information, we decided that Medicare rules for coverage of the 
 
 
transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for 
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when 
performed  (99306) provided June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from April 3, 2020, to May 21, 2020. 
 
You asked the Plan to pay for this service. You say that these claims should be paid by the Plan. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the 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 out of network physician 
services provided to the enrollee from April 3, 2020, to May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on June 11, 2020 and June 17, 
2020. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says prior 
authorization is required for all non-contracted providers. 
 
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 wound care services provided on June 11, 2020 and June 17, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81407 and 81408 provided on 
May 20, 2020. 
 
You asked the Plan to pay for the laboratory 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal were requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81407 and 81408 provided on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a free standing toilet frame. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the 
requested item is considered a personal comfort item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a free standing toilet frame.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on pulmonary surgery (32480, 
32674) provided by a surgical assistant on October 28, 2019. 
 
You asked the Plan to pay for surgical assistant services. You say that this provider was requested by the in-
network surgeon. The Plan denied your request. The Plan says surgical assistant services are not covered for 
this provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on 
pulmonary surgery (32480, 32674) provided by a surgical assistant on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 26, 
2020, to March 26, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from June 27, 2019, to 
February 25, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from February 26, 2020, to March 
26, 2020.