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

We decided that the Plan does not have to pay for the oral-facial images (D0350 x 4) provided on June 23, 2020. 
 
You asked the Plan to pay for the oral-facial images. You say that you were advised by a plan representative 
that you were covered 100% for dental services. You say that you were never advised that certain services 
would not be covered. You say that you would not have gone had you known. You also say that the services 
should be covered as you were given incorrect information. The Plan denied your request. The Plan says oral-
facial images are not listed as covered services. 
 
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, oral facial images are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral-facial images 
(D0350 x 4) provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fornursing facility care (99304) provided on April 8, 2020.You asked the Plan to pay fornursing facility care. You say that this provider is recognized by Medicare.The Plan denied your request. The Plan says that this provider is not eligible for Medicare.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. The reported NPI shows that thebilling provider is eligible to bill for their services. Though the Plan states that the provider billed with an incorrect taxonomy, the Plan has not provided a rule that would indicate that this is not payable.Therefore, we decided that the Plan has to pay fornursing facility care (99304) provided on April 8, 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 Neuromuscular stimulator, electronic shock unit (E0745) 
provided June 1, 2020. 
 
You asked the Plan to pay for electronic shock unit. You say that please refer to the attached medical records 
which clearly show medical necessity from the ordering physician. The Plan denied your request. The Plan 
says there is no actual physical exam. All information was provided over the phone. There are no clinical notes 
from the enrollee's primary health provider and no documented attempts to contact the enrollee's local 
physician and the enrollee is not in an eligible geographical area for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
 
 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Neuromuscular stimulator, 
electronic shock unit (E0745) provided June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for an inpatient hospital stay. We decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay.  
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think you 
should be charged with this stay. The Plan says that the correct copayment has been applied. 
 
We decided that the Plan has to reduce the copayment for an inpatient hospital stay.  
 
The total amount you should be asked to pay is $975 ($325 x 3 days = $975). 
 
We also decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
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 per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
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 the neuromuscular stimulator provided from April 15, 2020, 
to May 15, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item provided is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter.  
 
 
 
 
 
Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, 
we decided that the Plan does not have to pay for the neuromuscular stimulator provided from April 15, 2020, 
to May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided to you by an out-of-network 
provider on July 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you do not have out-
of-network benefits. 
 
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 vision services provided to you by an out-of-network provider on July 24, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray of chest (71045) provided on July 29, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the X-ray of chest. 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 X-ray of chest (71045) provided on July 29, 
2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on June 25, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you feel that the X-ray should be 
included in the surgery package. 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 an $85 
copayment for basic radiology provided in an outpatient hospital facility.  
 
You received an X-ray on June 25, 2020, at an outpatient hospital facility. X-rays are not included in post-
surgical follow-ups. Therefore, you are responsible to pay the $85 copayment.  
 
You have been asked to pay an $85 copayment for an X-ray. An X-ray falls within the outpatient diagnostic 
tests and therapeutic services and supplies 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 X-ray provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine received on August 3, 2020. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine received on August 
3, 2020.  
 
Benefits for the Shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 20, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were told that you would not 
owe a copayment. 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 $0 - $90 
copayment for emergency care. You pay $0 if you are admitted to the hospital within 24 hours for the same 
condition and for worldwide coverage. 
 
You have been asked to pay $90 copayment for emergency care. Emergency care 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 emergency care provided on 
May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71045) provided July 31, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the x-ray was medically necessary. The Plan denied 
your request. The Plan says the service billed shares a column I / column II relationship with another 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 71045 
has a column I / column II relationship with code 32555 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 a chest x-ray (71045) provided July 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz (J7321). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Synvisc/Synvisc-One or Euflexxa. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz (J7321). Our reviewer says that 
the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records 
provided the enrollee has not tried and failed the required drugs. Based on the medical records provided there is 
no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for 
the enrollee. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz (J7321) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided by Orthotic Prosthetic Center on June 
22, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that this is medically necessary because of you had a 
stroke. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by Orthotic 
Prosthetic Center on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee. 
 
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 per Medicare guidelines the SI for procedure codes denied with 5547 are N and Q1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the denied codes are not supported in the medical record. Specifically, these services are not 
separately payable in this case, as there is a status indicator of (SI)=N. 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 outpatient services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered. 
 
You asked the Plan to waive the copayments for these services. You say that you called the Plan and a 
recording stated that copayments were being waived. The Plan denied your request. The Plan says the 
copayments were 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 $150 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.  
 
Review of the file shows that you received outpatient surgical services to your eyes. You have been asked to 
pay a $150 copayment per date of service for these services, for a total of 
$300. These services fall within the Medicare-covered surgery or other services provided to you at an 
ambulatory surgical center 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.  
 
The file shows that the Plan stated that some cost sharing would be waived for COVID-19 testing. Surgical 
services do not quality for waiver of copayments. Therefore, we decided that the Plan does not have to waive 
the copayments for the outpatient surgical services rendered.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laser vaporization of the prostate 
provided. 
 
You asked the Plan to waive the copayment for the laser vaporization of the prostate. You say that you feel 
worse than before the procedure and 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $250 copayment for the laser vaporization of the prostate. The laser vaporization 
of the prostate 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 
the laser vaporization of the prostate provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acne surgery, incision and drainage procedures on the skin, 
subcutaneous and accessory structures (10040) provided June 16, 2020. 
 
You asked the Plan to pay for the acne surgery. You say that you did not know it was considered acne and was 
not covered. You were in office about 15 minutes and she took out 2 spots. She never told you it was not 
covered by insurance. The Plan denied your request. The Plan says cosmetic surgery or procedures are 
excluded and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the acne surgery have not been met. Therefore, we decided that the Plan does not have to pay for 
acne surgery, incision and drainage procedures on the skin, subcutaneous and accessory structures (10040) 
provided June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on March 16, 2020.You asked the Planto pay forthe services. You say that the procedure was initiated through Telemed.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 22, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment 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 $25 
copayment for in-network specialist's office services.  
 
Review of the file shows that you received specialist services on June 22, 2020. You have been asked to pay a 
$25 copayment for these services. These services fall within the in-network specialist's office 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 copayment for the specialist services rendered on June 22, 2020.