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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on March 
2, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the hospital should have 
covered the bill. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room 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 an emergency room visit (99283) on March 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care and closed treatment of posterior 
pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum 
provided on November 13, 2019. 
 
You asked the Plan to pay for the initial hospital care and closed treatment of posterior pelvic ring issues. You 
say that the enrollee fell and sustained a pelvic fracture. The Plan denied your request. The Plan says the 
enrollee was enrolled in hospice on this date of service. The Plan also says that these services need to be billed 
to Original Medicare for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care and closed treatment of posterior 
pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum 
provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP supplies you received on May 15, 
2020. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that the provider sent you the 
wrong equipment initially, so you shouldn't be charge. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly.  The plan understands that you initially received incorrect equipment.  
However, you were sent correct equipment on June 3, 2020 for which you were not charged.  You have not 
been doubled charged, so there is no reason to waive this cost sharing. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the 
durable medical equipment 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 CPAP 
supplies you received on May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on April 9, 2020 and 
April 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that if you are in the hospital, and need 
these drugs, your insurance plan should cover the cost of them. The Plan denied your request. The Plan says 
these drugs are self-administered, and are not Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on April 9, 2020 and April 10, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit (99214), an 
ultrasound of the chest (76604), and 2 ultrasounds of the arm or leg (76882) performed on April 17, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and 3 ultrasounds. You say that you 
should be charged only a $110 copayment for the 3 ultrasounds and a $25 copayment for the specialist office 
visit. The Plan denied your request. The Plan says the correct copayments were 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and that you must 
pay a $25 copayment for services obtained from a specialist.  
 
You have been asked to pay a $187.14 copayment, or $66.24 for an ultrasound of the chest and $47.95 for each 
ultrasound of the arm or leg, and $25 for a specialist office visit. Ultrasounds fall within the "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been 
asked to pay less than the full amount for 3 ultrasounds based on your contract with the Plan. A specialist office 
visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. This 
means that you have been asked to pay the correct amount for a specialist office visit 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 a specialist office visit (99214), 
an ultrasound of the chest (76604), and 2 ultrasounds of the arm or leg (76882) performed on April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year 
and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT Code 99100) 
provided on March 11, 2020. 
 
You asked the Plan to pay for the services. You say that the service was provided in search of the source of 
your infection that you were hospitalized for. The Plan denied your request. The Plan says the Medicare rules 
have not been met. 
 
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 services have not been met. You will not be held responsible 
for the cost of this service as payment for the services provided is already included in the approved anesthesia 
procedure. Therefore, we decided that the Plan does not have to pay for anesthesia for patient of extreme age, 
younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) 
(CPT Code 99100) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the six extractions of an erupted tooth requiring removal of 
bone and/or sectioning of tooth, two alveoloplasties in conjunction with extractions, two extractions of an 
erupted tooth or exposed root, four removals of residual tooth roots, and inhalation of nitrous oxide/analgesia 
provided on January 31, 2020. 
 
You asked the Plan to pay for the extractions, alveoloplasties, and removals of residual tooth roots. The Plan 
denied your request. The Plan says alveoloplasty is not a covered benefit. The Plan also says that the enrollee's 
extractions benefit 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, alveoloplasty in conjunction with 
extractions is not among those covered under this benefit. The Plan contract states that extractions are limited 
to two procedures per calendar year. The record shows that the enrollee received 14 extractions on January 31, 
2020, two of which have been covered by the Plan, and the enrollee's extractions benefit has been exhausted.  
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the six extractions of an erupted tooth requiring 
removal of bone and/or sectioning of tooth, two alveoloplasties in conjunction with extractions, two extractions 
of an erupted tooth or exposed root, four removals of residual tooth roots, and inhalation of nitrous 
oxide/analgesia provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace and the knee brace with related 
accessories/additions provided on March 31, 2020. 
 
You asked the Plan to pay for the braces. You say that the documentation supports the billed braces. The Plan 
denied your request. The Plan says there is no valid proof of delivery and the claims were not billed with the 
required KX modifier. 
 
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. Neither the invoice nor the delivery confirmation 
matches the billed date of service. 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 the back brace 
and the knee brace with related accessories/additions provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on January 20, 2020. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided 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 was 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 testing provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for an office visit provided on March 12, 
2020. 
 
You asked the Plan to waive the cost sharing for an office visit. You say that you disagree with how your cost 
sharing was calculated. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $110 combined in-network and out-of-network deductible for covered 
medical services. Your contract with the Plan also says that enrollees must pay a 15% coinsurance for in-
network services obtained from a primary care provider or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's 
office (as permitted under Medicare rules). 
 
The item or service you asked the Plan to waive the cost sharing for falls within the benefit category 
Physician/Practitioner Services, Including Doctor?s Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $110 combined in-network and out-of-network deductible for 
covered medical services. At the time this claim was processed, $25.82 of the $110 had been met, leaving a 
deductible amount of $84.18. The billed amount of the claim is $142, resulting in an $84.18 deductible. The 
remaining charges total $57.82, resulting in a coinsurance amount of $8.67 ($57.82 x 15%). Therefore, your 
total cost sharing obligation is $92.85 ($84.18 + $8.67). 
 
 
 
 
 
 
This cost sharing is a contractual obligation that had not been met at the time an office visit was received on 
March 12, 2020. Therefore, we decided that the Plan does not have to waive the cost sharing for an office visit 
provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on March 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on March 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. The provider billed procedure code 85060. This code has a status 
indicator of 8 and was not performed at the inpatient hospital setting. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 29, 
2019 to December 30, 2019. 
 
You asked the Plan to pay for the self-administered drugs. You say that you contacted the Plan and were told 
you needed to make a copay, which you did in February 2020. You also say that you were told that no further 
payment should be made. The Plan denied your request. The Plan says self-administered drugs are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from December 29, 2019 to December 30, 2019.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 16, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration because this provider relies on the facility staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 16, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service (11042) rendered by the out of 
network (OON) provider on October 17, 2019. 
 
You asked the Plan to pay 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 the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
October 17, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 21, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the treating provider depends 
upon the hospital staff to verify eligibility, and to obtain the proper authorization from the enrollee's insurance 
company. You also say that the treating provider rendered medically necessary services to the enrollee in good 
faith. The Plan denied your request. The Plan says the services were not provided by a network provider. The 
Plan also says that the services were not authorized by the Plan. 
 
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 subsequent nursing facility care provided on 
October 21, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment charged for outpatient therapy provided on 
March 16, 2020. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. 
The Plan denied your request. The Plan says this copayment was charged based on the service provided and the 
Plan contract agreement. 
 
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 $40 
copayment for outpatient therapy. 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 $40 copayment charged for outpatient therapy 
provided on March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling 
provided to the enrollee on September 16, 2019. 
 
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 Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for NSCLC. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360 molecular pathology genomic profiling provided to the enrollee on September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on October 16, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were provided at a skilled 
nursing facility. You say that these services were requested by the rendering physician. The Plan denied your 
request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care 
physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 skilled nursing services provided on October 16, 
2019 by an out of network (OON) provider.