Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and re-cement or re-
bond crown provided on January 3, 2020. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and re-cement or re-bond crown. You 
say that you were not aware the 6-month period was not met. You say that you would have waited for 6 more 
days. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 also have a maximum benefit of 
one prophylaxis and oral evaluation every 6 months. The Plan paid for a prophylaxis and oral evaluation 
provided on July 9, 2019, which exhausted the benefit. The re-cement or re- bonding of a crown is not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis, periodic oral 
evaluation and re-cement or re-bond crown provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 4, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on March 4, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on October 29, 2019. 
 
You asked the Plan to pay for the surgical procedure at the out-of-network surgical center. You say that the 
physician's office told you the procedure would continue as scheduled at this facility. The Plan denied your 
request. The Plan says that your contract provider did not request authorization and you are not responsible for 
this bill. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the surgical procedure at the out-of-network surgical center by a contract provider. The 
file does not show that the Plan provided notice that the surgical procedure at the out-of-network surgical 
center would not be covered. Under Medicare rules, this means the surgical procedure at the out-of-network 
surgical center is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
services provided on October 29, 2019.  
 
 
 
 
 
 
 
 
 
 
 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 17, 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 testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery (20611LT) and 
injection services (J7327JG) provided December 3, 2019. 
 
You asked the Plan to waive the copayment for the outpatient surgery and injection services. You say that you 
are requesting the plan to waive the copayment. This is planned as a repeat procedure every 6-9 months and 
hope you would not have to keep appealing these charges. The Plan denied your request. The Plan says the cost 
shares were applied correctly per the plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 
copayment per visit and 20% coinsurance for each Medicare covered Part B drug. 
 
You have been asked to pay $375. 04 for the outpatient surgery and injection services. The outpatient surgery 
and injection services falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers and 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 copayment for the outpatient surgery (20611LT) and injection services 
(J7327JG) provided December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided January 6, 2020 to 
January 18, 2020. 
 
You asked the Plan to pay for post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan hospital for 
post-stabilization treatment. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for post-stabilization inpatient care. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found based on the 
documentation, the patient had stable vitals and was stable for transfer to an in-network facility after initial 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization inpatient care have not been met. Therefore, we decided that 
the Plan does not have to pay for post-stabilization inpatient care provided January 6, 2020 to January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 4, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order for the tests billed and some of the tests do not match the specimen 
type obtained for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on December 4, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from January 7, 2020 to January 31, 
2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says authorization is 
required and 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 did not pre-approve the 
SNF 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 SNF services provided from January 7, 2020 to January 31, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care received from 
November 19 to November 21, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not realize you 
were receiving inpatient hospital care. 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 $225 
copayment per day per admission for days 1-5 for inpatient hospital care.  
 
You have been asked to pay $450 ($225 per day) for inpatient hospital care. You received inpatient hospital 
care from November 19 to November 21, 2019. The Plan contract also says that inpatient hospital care starts 
the day you are formally admitted to the hospital with a doctor's order and that the day before you are 
discharged is your last inpatient day. Therefore you received 2 days of inpatient hospital care. 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 inpatient hospital care received from November 19 to November 21, 
2019.  
 
Your complaint that the hospital is not offering you a payment arrangement that you find acceptable is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) provided on September 16, 2019. 
 
You asked the Plan to pay for hospital care. You say that the patient had multiple exams. The Plan denied your 
request. The Plan says payment for this service is included in the payment for another procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We looked at the file and Medicare rules. The record shows the service at issue was performed on the same day 
by the same physician as a drainage procedure (49406). Based on this information, we decided that Medicare 
rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay 
for hospital care (99232) provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 18, 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, 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 March 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a repair of a tendon of the upper eyelid 
(67904) performed on July 11, 2019. 
 
You asked the Plan to waive the copayment for a repair of a tendon of the upper eyelid. You say that you were 
told the copayment would be waived. 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 $290 
copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital 
outpatient facility.  
 
You have been asked to pay a $290 copayment for a repair of a tendon of the upper eyelid. A repair of a tendon 
of the upper eyelid falls within the Outpatient surgery 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 a repair of a tendon of the upper eyelid (67904) performed on July 11, 2019.  
 
Your complaint about the provider not honoring a prior arrangement to not charge the copayment is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit (G0463) 
provided December 5, 2019. 
 
You asked the Plan to waive the copayment for the hospital outpatient clinic visit. You say that you are 
appealing because you were not advised that you had a copay at the time of the visit. The Plan denied your 
request. The Plan says when the allowed amount is less than the copayment amount, you are only responsible 
for the lesser 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 $300 
copayment for Medicare covered services in a hospital outpatient facility.  
 
You have been asked to pay $117.57. The contract says you must pay $300 copayment for Medicare covered 
services in a hospital outpatient facility. However, when the allowed amount is less than the copayment 
amount, you are only responsible for the lesser amount. The hospital outpatient clinic visit falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 hospital outpatient clinic visit 
(G0463) provided December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance mileage (A0888) from a transport provided April 
3, 2020. 
 
You asked the Plan to pay for the ambulance mileage. You say that the mileage should be covered. The Plan 
denied your request. The Plan says mileage is only covered to the nearest appropriate facility. 
 
The Plan must follow Medicare rules. Medicare rules say that only mileage to the nearest appropriate facility 
equipped to treat the patient is covered.  
 
We looked at the file and Medicare rules. The record shows the transport bypassed the nearest appropriate 
facility for a farther facility. The enrollee's needs could have been met at the nearest hospital facility. Based on 
this information, we decided that Medicare rules for coverage of the ambulance mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance mileage (A0888) from a transport 
provided April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 17, 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 testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific criteria are met.

We looked at the file and Medicare rules. There is no clinical information to support that the criteria for testing are met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on December 9, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the diagnosis codes submitted on the claim are not found to be codes that 
support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate diagnostic code. Medicare has established limited coverage 
for the CPT code 00731. 
 
We find that CPT code 00731 is not supported in the medical record. Specifically, the diagnosis codes 
submitted are not listed in the Local Coverage Article. Based on this information, we decided that Medicare 
rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services provided on December 9, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
April 27, 2020. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that the hospital would 
not admit because of insurance you so you were transferred to an in-network hospital where you were admitted. 
The Plan denied your request. The Plan says you were not admitted to the original hospital from the emergency 
room so your copayment cannot be waived. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay $90 copayment for the emergency room service. The emergency room service falls 
within the Emergency Care benefit category. You were not admitted to the same hospital as this emergency 
service was provided at. 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 emergency room service 
provided on April 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room Visit provided 
January 26, 2020 to January 28, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should 
be waived because the patient was admitted. The Plan denied your request. The Plan says the records do not 
show the enrollee was admitted as an inpatient. 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 $25 
copayment for Emergency Care.  
 
You have been asked to pay a $25 copayment for the Emergency Room visit. The Emergency Room visit falls 
within the Emergency 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 
Emergency Room Visit provided January 26, 2020 to January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an analysis and interpretation of an EKG 
report (93226) performed on February 5, 2020. 
 
You asked the Plan to waive the copayment for an analysis and interpretation of an EKG report. You say that 
you've been charged two copayments for one service. 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 $25 
copayment for each specialist visit.  
 
You have been asked to pay a $25 copayment for an analysis and interpretation of an EKG report. An analysis 
and interpretation of an EKG report 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 analysis and interpretation of 
an EKG report (93226) performed on February 5, 2020.