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

 
We decided that the Plan does not have to pay for an injection provided on February 20, 2020. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented.   
 
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 an injection provided on February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the EMT checked your blood pressure 
and opted not to take you to the hospital. 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 March 5, 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 March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 did not pre-approve the 
physician's services. 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 physician's services provided on May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 19, 
2020 to March 24, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges. 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 $325 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 19, 2020 to March 24, 2020. Therefore, you are responsible to 
pay $975, which is less than the total copayment amount.  
 
You have been asked to pay $975 for an inpatient hospital stay. An inpatient hospital stay falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay from March 19, 2020 to March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 31, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says member's must use in network providers to 
get medical care and 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 medical services provided on October 31, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing provided on July 24, 2019. 
 
You asked the Plan to pay for the presumptive screen. You say that the testing was medically necessary and 
should be covered. The Plan denied your request. The Plan says there is no evidence that the drug screening 
was provided. 
 
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 code 80307 is not supported in the medical record. Specifically, the lab report included does 
not document the results of the presumptive screening, nor does the order form indicate that it was requested. 
Based on this information, we decided that Medicare rules for coverage of the presumptive screen have not 
been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing provided 
on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis provided to the enrollee on April 11, 
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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician 
who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
In this case, the CPT Code Manual definition of HCPCS L3670 is "Shoulder orthosis (SO), acromio/clavicular 
(canvas and webbing type), prefabricated, off-the-shelf." 
 
We find that HCPCS code L3670 is not supported in the medical record. Specifically, the file does not contain 
documentation of an established relationship between the enrollee and the ordering provider. Without a record 
showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. 
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 a shoulder orthosis provided to the enrollee on 
April 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 13, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 psychotherapy services provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. 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 an office visit provided on April 27, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on February 3, 
2020 and February 4, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you feel that you should not be 
charged a copayment for the services rendered. 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 $45 
copayment for specialist services provided in an outpatient department. 
 
You received specialist services on February 3, 2020 and February 4, 2020. Therefore, you are responsible to 
pay a $45 copayment per each visit. The total amount you owe is: $90.   
 
You have been asked to pay the total copayment amount of $90 for specialist services. Specialist services fall 
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 specialist services provided on February 3, 2020 and February 4, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and crown 
provided on March 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and crown. You say that the office 
did not inform you that an oral exam was required. You also say that your benefits were not clearly explained 
to you. The Plan denied your request. The Plan says these services were rendered by a dentist who does not 
participate with your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 20% 
coinsurance for diagnostic and preventive services, and a 50% coinsurance for major restorative services 
received by an out-of-network dentist. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation and crown provided on March 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of broken teeth provided on May 11, 2020. 
 
You asked the Plan to pay for the replacement of broken teeth. You say that you feel that denture repair is 
important to your health. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
replacement of broken teeth provided on May 11, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Electrocardiogram interpretation (93010) provided 
February 21, 2020. 
 
You asked the Plan to pay for the Electrocardiogram interpretation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the service billed. 
 
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 93010 is ECG with at least 12 leads; interpretation and 
report only).  
 
We find that CPT code 93010 is not supported in the medical record. Specifically, a professional component 
billing based on a review of the findings of these procedures, without a complete, written report similar to that 
which would be prepared by a specialist in the field does not meet the conditions for separate payment of the 
service. Payment for a simple EKG reading is included in the payment for the Emergency Room services. 
Based on this information, we decided that Medicare rules for coverage of the Electrocardiogram interpretation 
have not been met. Therefore, we decided that the Plan does not have to pay for an Electrocardiogram 
interpretation (93010) provided February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on May 13, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges 
because you never paid for the services 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 $20 
copayment for specialist services.  
 
You have been asked to pay the allowed amount of $10.36, which is less than the $20 copayment for specialist 
services. Specialist services fall 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 specialist services provided on 
May 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injections rendered on 
March 11, 2020 and April 15, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were not told you would be 
responsible beyond your copay. The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
Review of the file shows that you received aflibercept injections on March 11, 2020 and April 15, 2020. You 
have been asked to pay a 20% coinsurance for these services, for a total of $753.89. These services fall within 
the Medicare-covered Part B drugs 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 
the aflibercept injections rendered on March 11, 2020 and April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on April 20, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you already paid your specialist 
copayment. You say that you are now receiving this additional bill and you do not agree with it. The Plan 
denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,920. The total amount you are being asked to pay is $384 ($1,920 x 20% = $384). An injection 
falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for an injection provided by a participating provider on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 30, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory services. 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 laboratory services provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415 82670, 83001, 83002 84146, 
84443, 84702 85027, 87491, 87591, G0123) provided on March 19, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for OON laboratory services. You say that these services should be covered. 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 laboratory services (36415 82670, 83001, 
83002 84146, 84443, 84702 85027, 87491, 87591, G0123) provided on March 19, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 9, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supplies used during ambulance transport provided 
on November 19, 2019. 
 
You asked the Plan to pre-approve the supplies. You say that the ambulance transport was medically necessary. 
The Plan denied your request. The Plan says that the supply should be included in the fee paid for transport and 
not charged extra. 
 
The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance 
services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services 
associated with such transport; and does not include a separate payment for items and services furnished under 
the ambulance benefit. Therefore, we decided that the Plan does not have to pre-approve the supplies used 
during ambulance transport provided on November 19, 2019.