Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear wax removal service provided on August 22, 2019 by 
an OON provider. 
 
You asked the Plan to pay for the ear wax removal service. You say that the enrollee has only ever been seen 
by in network providers. The Plan denied your request. The Plan says the service was rendered by an OON 
provider. The Plan also says that 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 ear wax removal service provided on August 
22, 2019 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the pain medication began to work when 
the ambulance arrived. 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 May 13, 2020. 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 provided on May 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit you had on July 10, 2019. 
 
You asked the Plan to reduce the copayment for the gynecology office visit. You say that you have only ever 
paid a $10 copayment for this service in the past. 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 $35 
copayment for visits with a specialist.  
 
You have been asked to pay a $35 copayment for the gynecology office visit. Gynecology services are 
considered specialist services. 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 reduce the copayment for the office visit you had on 
July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot tub rendered on May 15, 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 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 pay for the hot tub rendered on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forprofessional services for allergen immunotherapy provided on January 31, 2020.You asked the Plan to waive the copayment forprofessional services for allergen immunotherapy. You say that you disagree with the charges because they were covered 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 $35 copayment per visit to a specialist. You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for professional services for allergen immunotherapy. Professional services for allergen immunotherapy fallwithin the physician/practitioner services, including doctor's office visits 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 forprofessional services for allergen immunotherapy provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. 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 the 
drug testing services provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 14, 2020 and 
March 13, 2020 by an out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request prior authorization for the non-urgent 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 the physician services provided on February 14, 
2020 and March 13, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasounds provided on March 10, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that previously the rule is one 
copayment for multiple ultrasound procedures. You say that no wording in the Evidence of Coverage has 
changed for these identical procedures. The Plan denied your request. The Plan says the copayments 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a 
physician?s office or at a free-standing facility.  
 
You have been asked to pay a total of $329.22 for the ultrasounds.  
 
Service Allowed Amount Standard Copayment Member Liability 
Blood Flow Ultrasound $206.68 $110 $110 
Artery Ultrasound $109.22 $110 $109.22 
Artery Ultrasound $123.36 $110 $110 
TOTAL:   $329.22 
 
  
The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit 
category. The Evidence of Coverage states the copayment applies to each radiological diagnostic 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 ultrasounds provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services you received. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford this 
coinsurance. The Plan denied your request. The Plan says this coinsurance was charged 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 20% 
coinsurance for dialysis services.  
 
You have been asked to pay 20% coinsurance for the dialysis services.  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 dialysis services you received.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on July 27, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that your father was unaware that a 
copayment would be required. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment for ambulance services.  
 
The enrollee has been asked to pay a $350 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance trip provided by a participating provider on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an intraoral x-ray (D0210) provided on July 28, 2020. 
 
You asked the Plan to pay for an intraoral x-ray. You say that you were not aware of the limitation on this 
service. The Plan denied your request. The Plan says that this service is covered once every 36 months. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Although the Plan contract states this is covered only once every 36 months, the 
Plan has not submitted an explanation of benefits or other documentation supporting that this service was 
received and paid for in the past 36 months. Therefore, we decided that the Plan has to pay for an intraoral x-
ray (D0210) provided on July 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a compression device (E0676) provided on February 18, 
2020. 
 
You asked the Plan to pay for a compression device. You say that this is supported with the enrollee's 
diagnosis. The Plan denied your request. The Plan says sufficient records have not been submitted. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. There is not documentation of any physician evaluation or visit that supports the need for the item 
at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for a compression device (E0676) provided 
on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 27, 
2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel that the charges are too 
high. 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 $15 
copayment for primary care provider visits.  
 
You have been asked to pay a $15 copayment for an office visit. An 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 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 office visit provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 5, 2020 
by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services provided were 
medically reasonable and necessary. The Plan denied your request. The Plan says the service was rendered by a 
non-participating provider. The Plan also says that 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 subsequent nursing facility care provided on 
June 5, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the duplex scan provided on June 11, 2020. 
 
You asked the Plan to waive the deductible for the duplex scan. You say that you should have been notified 
about your deductible prior to getting a bill. You say that you've had this test done for the past 20 years and 
never received a bill before. The Plan denied your request. The Plan says the deductible applied correctly. 
 
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 your deductible is $250. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $250 deductible applies to diagnostic radiology. This cost sharing is a 
contractual obligation that had not been met at the time the duplex scan was received on June 11, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the duplex scan provided on June 
11, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tab 10mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication falls under Part D coverage, but the enrollee does not have a Part D 
pharmacy 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 pre-approve Xarelto tab 10mg for the 
enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayments for office visits. 
 
You asked the Plan to reduce the copayments for the office visits. You say that you should only have to pay a 
$10 copayment for these visits. The Plan denied your request. The Plan says that you were appropriately 
charged a $15 copayment per visit for specialty care because you did not change your PCP officially until 
February 1, 2020. 
 
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 enrollees must pay a $10 copayment per visit for visits with your PCP or other 
primary care provider. You pay a $15 copayment for visits with a specialist. 
 
Your Plan charged you a $15 copayment for each visit with this provider, stating that the provider is considered 
a specialist because you had not changed your PCP designation prior to these services.  We do not find this 
argument persuasive.  While we agree that you had not officially changed your PCP to this provider until after 
the dates of service in question, the fact remains that this provider is not a specialist.  This doctor is an internal 
medicine physician, which is a type of primary care provider. Your EOC clearly states that the $10 copayment 
applies not only to visits with your PCP, but also to visits with ANY primary care provider.  Based on the Plan 
contract, you cannot be asked to pay more than $10 per visit for these office visits. Therefore, we decided that 
the Plan has to reduce the copayments for office visits.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and bone grafts at the 
time of placement (D6104) for teeth # 6 and 11. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says prefabricated abutments are not listed as covered. The Plan says that 
bone grafts at the time of placement are not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve 
prefabricated abutments (D6056) and bone grafts at the time of placement (D6104) for teeth # 6 and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on April 2, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have had these lab services 
in the past and have never been charged a 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 $50 
copayment for lab services provided in an outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for the lab services. 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 lab services you received on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography, professional interpretation, 
provided on June 10, 2020. 
 
You asked the Plan to pay for the needle electromyography, professional interpretation (95861). You say that 
the Plan should pay this claim at the in network level. The Plan denied your request. The Plan says the 
Medicare rule for payment of this claim has not been met. 
 
The Plan must follow Medicare rules. The rules state that the professional interpretation of a diagnostic test 
must be separately billed with modifier -26.   
 
The claim was not submitted with the required -26 modifier. Based on this information, we decided that 
Medicare rules for needle electromyography, professional interpretation, have not been met. Therefore, we 
decided that the Plan does not have to pay for the needle electromyography, professional interpretation, 
provided on June 10, 2020.