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

We decided that the Plan does not have to waive the copayment for the skin biopsy provided on February 14,
2020.
You asked the Plan to waive the copayment for the skin biopsy. You say that this was an office visit not same
day surgery or observation. 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 $275
copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital
outpatient facility.
You have been asked to pay $215.04, which is less than the standard $275 copayment for the skin biopsy. The
skin biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. The skin biopsy is considered a surgical procedure. 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 skin biopsy provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 30,
2019.
You asked the Plan to pay for the dental services. You say that you have been a member of the plan for
fourteen (14) years and have never received information on what is covered. The Plan denied your request. The
Plan says the service is not a covered benefit under the 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, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910)
provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge care (99217) provided on October 16,
2018.
You asked the Plan to pay for the observation discharge care. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says CPT code 99217 was also billed
and paid on a different claim for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 99217 is 1. You billed 2 units of this code, exceeding the MUE for the
same date of service. Based on this information, we decided that Medicare rules for coverage of the observation
discharge care have not been met. Therefore, we decided that the Plan does not have to pay for observation
discharge care (99217) provided on October 16, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428, A0425) provided January 3, 2019.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary and properly billed. The Plan denied your request. The Plan says the service is not separately payable.
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 A0428, A0425 is not supported in the medical record. Specifically, the ambulance transport was provided during an inpatient admission. The service is not separately billable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428, A0425) provided January 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220)
provided on January 15, 2020.
You asked the Plan to pay for the dental services. You say that your plan includes x-rays at a $0 copayment.
The Plan denied your request. The Plan says the service is not a covered benefit under the 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, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first
radiographic image (D0220) provided on January 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from January 1, 2020 through
January 14, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you were not at the facility during this
period of time and should not be responsible for the cost-sharing. The Plan denied your request. The Plan says
the claim was processed accordingly with your 2019 EOC 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).
Review of the file show that you received SNF care from January 1, 2020 through January 14, 2020. You are
asked to pay a $0 copay per day for days 1-20, then $178 copay per day for days 21-100. You were receiving
services at the facility during this timeframe, therefore, you are responsible for your cost-share. 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 SNF care from January 1, 2020 through January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided on January 16, 2020.
You asked the Plan to pay for the dental services. You say that your old provider is no longer participating with the plan and you had to get a new in-network dentist to have an oral evaluation and panoramic radiographic image. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. Your EOC states that a comprehensive exam has a frequency limit of one procedure per three plan years and panoramic radiographic image has a frequency of one procedure per three plan years. You had the same service on January 03, 2018 and July 10, 2018 which were processed and paid by the plan. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from November 27,
2019, to December 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
covered.
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.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services you received from November 27, 2019, to
December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion solution (J7050, Q9967) provided January 16, 2020.
You asked the Plan to pay for the infusion solution. You say that the services were medically necessary. The Plan denied your request. The Plan says the codes billed are not separately payable.
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 J7050, Q9967 is not supported in the medical record. Specifically, payment for these codes is included in the primary procedure. Infusion solution cannot be separately billed. Based on this information, we decided that Medicare rules for coverage of the infusion solution have not been met. Therefore, we decided that the Plan does not have to pay for infusion solution (J7050, Q9967) provided January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and gingival irrigation - per quadrant (D4921) provided on January 20, 2020.

You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 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, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and gingival irrigation - per quadrant (D4921) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care services and the physician services from July 26, 2019 to September 20, 2019.
You asked the Plan to waive the copayments for the wound care services and the physician services. You say that you were told there would not be any copayments for the services. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 for specialist services (including surgery second opinion and telehealth or urgently needed services) and a $35 copayment for each Medicare-covered podiatry visit. You have been asked to pay a $35 copayment for the wound care services and the physician services on each date of service. ($35 x 4 dates of service = $140). The wound care services fall within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The physician services fall within the "Podiatry 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 waive the copayments for the wound care services and the physician services from July 26, 2019 to September 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health visits (90834)
provided June 8, 2019 to August 26, 2019.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the
copayment should be waived. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment per visit for Outpatient Mental Health services.
You have been asked to pay a $200 in copayments for 5 outpatient mental health visits. 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 outpatient mental health visits (90834) provided June 8, 2019 to
August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - four or more surfaces or involving
incisal angle (anterior) (D2335) provided on February 11, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for resin-based composite - four or
more surfaces or involving incisal angle (anterior) (D2335) provided on February 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF care is necessary. The Plan denied your request. The Plan says the services you require could be provided at an alternative level of care so Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require skilled physical and occupational therapy, you do not require treatment in an intensive rehabilitation therapy program. Another level of care would be more appropriate for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen concentrator (E1392) purchased on
September 30, 2019 from an out-of-network provider.
You asked the Plan to pay for the oxygen equipment (E1392). You say that you needed the equipment for a trip
you were taking and you purchased it because the company that sold it to you told you that your insurance
would cover the cost for you. The Plan denied your request. The Plan says the Medicare rules have not been
met.
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.
Furthermore, Medicare rules state that only rented oxygen equipment is eligible for coverage. Purchased
oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for
portable oxygen concentrator (E1392) purchased on September 30, 2019 from an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
December 16, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this was a transfer
between the hospital and rehabilitation center. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $200 copayment for Medicare-covered ambulance transport (one-way).
The enrollee has been asked to pay a $200 copayment for the ambulance transport. The ambulance transport
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 the ambulance transport provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided
on January 27, 2020.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that you only paid
$194 before. You say that you will not continue to get this shot at the higher price. The Plan denied your
request. The Plan says the coinsurance 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 20%
coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other
Medicare Part B drugs from an in-network provider.
You have been asked to pay $1,318.10, which is 20% of the allowed amount for the leuprolide acetate
suspension. The allowed amount is $6,590.49 (20% x $6,590.49 = $1,318.10). The leuprolide acetate
suspension 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 the leuprolide acetate suspension provided on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for train-of-four testing (95999) provided November 21, 2019.
You asked the Plan to pay for the train-of-four testing. You say that the service was medically necessary and
properly billed. The Plan denied your request. The Plan says payment for this service is bundled in payment for
the primary neuromonitoring 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, we have confirmed that code 95999
has a bundled relationship with the intraoperative neuromonitoring already paid and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for train-of-four testing (95999)
provided November 21, 2019.