Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 15, 
2020, through July 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that this bill is a hardship for you. 
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 $295 
copayment per day, for days 1 to 6 for each Medicare-covered hospital stay. 
 
You have been asked to pay a $1,475 copayment for the inpatient stay. ($295/day x 5 days = $1,475). Please 
note, the Plan has confirmed the remaining amount you owe is $1,385. The inpatient 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 the inpatient 
stay provided from July 15, 2020, through July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on July 30, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you cannot afford to pay for the root canal. 
The Plan denied your request. The Plan says this service is not a covered benefit under 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, 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 
endodontic therapy (D3320) provided on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for the EKG. 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to 
EKG?s, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests.  
 
You have been asked to pay $19.55, which is less than the standard $30 copayment for the EKG. The EKG 
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 the EKG provided on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on November 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on June 23, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you would like reconsideration because you 
were told this service is covered once per calendar year. The Plan denied your request. The Plan says this 
benefit has been exhausted. 
 
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. Specifically, the record indicates that you received bitewing x-rays on 
August 29, 2019. The Plan covers this service once every 12 months so you were not eligible to receive 
additional bitewing x-rays on June 23, 2020. Therefore, we decided that the Plan does not have to pay for 
bitewing x-rays (D0274) provided on June 23, 2020.  
 
Your complaint about receiving incorrect information 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 copayments for the routine eye exam and refraction 
rendered on July 1, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
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 $50 
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  
 
Review of the file shows that you received an eye exam and eye refraction on July 1, 2020. You have been 
asked to pay a $50 copayment per service for these services, for a total of $100. These services fall within the 
each Medicare-covered exam to diagnose and treat diseases or conditions of the eye 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.  
 
It is noted that the Plan contract states there is a $0 copayment for one routine vision exam and refraction; 
however, the provider did not bill these services as routine. You may wish to ask the provider to rebill the 
services as routine to the Plan?s vision insurance. 
 
Therefore, we decided that the Plan does not have to waive the copayments for the routine eye exam and 
refraction rendered on July 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on June 4, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were sent for a test that they 
don't do. You say that you were billed when they did nothing. 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 $90 for 
each Medicare-covered emergency room visit. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that laboratory services were provided, and you were advised to continue 
taking your medication and to follow up with a specialist. 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 ER visit provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the additional intraoral x-ray (D0230) 
provided on June 24, 2020. 
 
You asked the Plan to pay the in network rate for the additional intraoral x-ray. You say that office associate 
advised she would get it approved before you came in for your appointment. You say that you were given x-
rays done that you did not ask for. You say that you received a cleaning that you never wanted done since a 
tooth broke last time you did. You say that when you left your appointment, you were advised that you did not 
owe anything. You also say that you were not told that the provider was out of network. The Plan denied your 
request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan also says that the frequency limit 
has been exceeded. 
 
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 frequency limit of 1 intraoral x-ray 
per calendar year has been exceeded. The record shows that the Plan paid for the initial intraoral x-ray that you 
received on this date of service. Therefore, we decided that the Plan does not have to pay the in network rate 
for the additional intraoral x-ray (D0230) provided on June 24, 2020.  
 
Your complaint about not wanting a cleaning because a piece of your tooth fell off last time 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 the breath test provided on April 26, 2020. 
 
You asked the Plan to pay for the breath test. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a Lactulose breath hydrogen test for diagnosing 
small bowel bacterial overgrowth and measuring small bowel transit time is not covered.  
 
We looked at the file and Medicare rules. The requested breath test is non-covered per NCD 100.5. Based on 
this information, we decided that Medicare rules for coverage of the breath test have not been met. Therefore, 
we decided that the Plan does not have to pay for the breath test provided on April 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic services provided on August 12, 2020. 
 
You asked the Plan to pay for the services provided. You say that the additional treatment should be covered 
due to the unusual circumstances. The Plan denied your request. The Plan says the service is not a covered 
benefit under 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the provided endodontic services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
endodontic services provided on August 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 28, 
2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the service should be covered. 
The Plan denied your request. The Plan says the copayment is correct. 
 
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 outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for physical therapy. This service falls within the outpatient 
rehabilitation 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 physical 
therapy provided on August 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 31, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 31, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 31, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy (PT) services rendered on May 29, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount has been reached for therapy. 
 
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 Plan states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy (PT) services rendered on May 29, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the established patient office or other 
outpatient visit with routine electrocardiogram (99214, 93000) provided on February 25, 2020. 
 
You asked the Plan to waive the copayment for the established patient office or other outpatient visit with 
routine electrocardiogram. You say that you disagree with the copayment as charged. The Plan denied your 
request. The Plan says the copayment applied correctly in this case. 
 
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 $30 
copayment for non-radiological diagnostic services and $40 copayment for consultation, diagnosis, and 
treatment by a specialist. 
 
You have been asked to pay a total cost share amount of $54.90 ($40 plus $14.90). $40 copayment is the total 
for the specialist office visit and the $14.90 copayment is the total for the non-radiological diagnostic services 
which is less than the required $30 copayment for non-radiological diagnostic services. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the established patient office or other outpatient visit with routine 
electrocardiogram (99214, 93000) provided on February 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299) provided February 11, 2020 to 
March 19, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not filed correctly. 
 
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 G0299 is not supported in the medical record. Specifically, code G0299 has a status 
indicator equal to "X" on the physician fee schedule which is not in the statutory definition of physician 
services for fee schedule payment purposes. Home Health Skilled Nursing services must be reported on HH 
PPS claims with the corresponding revenue code. Based on this information, we decided that Medicare rules 
for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have 
to pay for home health services (G0299) provided February 11, 2020 to March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) provided on February 28, 2020. 
 
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the laboratory results have not been submitted for the 
billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 
We find that CPT code G0480 is not supported in the record. Specifically, the record does not include 
sufficient documentation to determine whether payment is due and the amount of payment. There is 
insufficient documentation to confirm that Medicare coverage criteria have been met. Based on this 
information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug test (G0480) provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block provided on May 26, 2020. 
 
You asked the Plan to pay for the provided service. The Plan denied your request. The Plan says the use of the 
treatment has not been studied for management of the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. In this case, there were insufficient medical records to support the 
need for the billed services. Based on this information, we decided that Medicare rules for coverage of the 
provided service have not been met. Therefore, we decided that the Plan does not have to pay for the genicular 
nerve block provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on August 11, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you have never had to pay for 
this services before. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $40 copayment for specialist services. Since specialist services were provided, 
the correct copayment has been applied. Specialist services fall within the physician/practitioner services/in-
network/specialist 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 by a participating provider on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyPro Motion G Powered Arm Brace (L8702). 
 
You asked the Plan to pre-approve a MyPro Motion G Powered Arm Brace. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is not information to show this would be more 
effective than a traditional orthosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a MyPro Motion G Powered Arm 
Brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the literature is insufficient in terms out effectiveness and safety of this 
device for the patient's condition. At this time, the requested orthosis is not proven to be more beneficial for 
treatment of the patient's medical condition of hemiparesis after stroke than any available standard therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyPro Motion G Powered Arm Brace have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyPro Motion G Powered Arm Brace (L8702).