Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the insertion of a pacemaker. 
 
You asked the Plan to waive the coinsurance for the insertion of a pacemaker. You say that you were never 
informed of the charges prior to receiving the procedure. 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 20% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received the insertion of a pacemaker. The total allowed amount is $7,868.24 and 
20% of that is $1,573.65.  
 
You have been asked to pay the total coinsurance amount of $1,573.65 for the insertion of a pacemaker. The 
insertion of a pacemaker falls within the outpatient surgery and other medical 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 
coinsurance for the insertion of a pacemaker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care service provided on March 21, 2020. 
 
You asked the Plan to pay for critical care. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the records submitted do not 
support the code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient, first 30 to 74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not support 
that this critical care service was 30 to 74 minutes in duration. Based on this information, we decided that 
Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care service provided on March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on October 23, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0428) received 
on January 27 and March 24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that no one can afford these 
charges. The Plan denied your request. The Plan says the enrollee was charged this cost sharing 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 $250 copayment for each ambulance trip. The enrollee had 2 ambulance trips. The Plan charged the 
enrollee $250 for each of these services. 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 
when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services (A0428) received on January 27 and March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on October 22, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the ambulance transport services provided on 
August 17, 2019. 
 
You asked the Plan to reimburse you for the ambulance transport services. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says ambulance transport 
services to a physician's office does not meet destination requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to reimburse you for are ambulance transport services to a doctor's 
office. Therefore, we decided that the Plan does not have to reimburse you for the ambulance transport services 
provided on August 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy(S9328) provided on November 14, 
2019, through March 10, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Medicare. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy(S9328) provided 
on November 14, 2019, through March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for fluoroscopic guidance and a Medicare Part 
B drug provided on May 20, 2020. 
 
You asked the Plan to waive the coinsurance for fluoroscopic guidance and a Medicare Part B drug. You say 
that you paid the $35 copayment and disagree with the additional 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 20% 
coinsurance for diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for Medicare Part B prescription drugs.  
 
You received fluoroscopic guidance on May 20, 2020. The allowed amount is $110 and 20% of that is $22. 
 
You received a Medicare Part B drug on May 20, 2020. The allowed amount is $12 and 20% of that is $2.40.  
 
The total amount you owe is: $24.40.  
 
You have been asked to pay the total coinsurance amount of $24.40 for fluoroscopic guidance and a Medicare 
Part B drug. Fluoroscopic guidance falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. A Medicare Part B drug 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 fluoroscopic guidance and a 
Medicare Part B drug provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit (99308) provided on January 8, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility visit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 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 nursing facility visit (99308) provided on 
January 8, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (47563) provided 
be a Licensed Surgical Assistant (LSA) on February 27, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that you should not be responsible for getting 
the doctor's credentials. The Plan denied your request. The Plan says this provider cannot be paid for these 
services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a 
laparoscopy (47563) provided be a Licensed Surgical Assistant (LSA) on February 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services provided 
from January 10, 2020 to February 13, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that you disagree 
with the charges and request a refund. 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 30% 
coinsurance for out-of-network outpatient rehabilitation services.  
 
You received outpatient rehabilitation services from an out-of-network provider from January 10, 2020 to 
February 13, 2020 for a total of 6 visits. The total allowed amount is $856.90 and 30% of that is $257.08.  
 
You have been asked to pay the total coinsurance amount of $257.08 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall 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 coinsurance for outpatient rehabilitation services provided from January 10, 2020 to 
February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospitalist services provided to the enrollee on February 23, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service was not urgent or emergent. 
 
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 hospitalist services provided to the enrollee on 
February 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3320) provided on July 8, 2020. 
 
You asked the Plan to pay for the dental service. You say that when you went to get dentures you also had a 
root canal. You say that you told the dentist that you did not want a root canal. You say that the dentist 
performed a root canal anyways. You also say that you are now stuck with a $1,123 bill. The Plan denied your 
request. The Plan says your $2,000 allowance for supplemental preventive and comprehensive dental services 
has been exhausted. The Plan also says that you are responsible for any amount over the allowance amount.  
 
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 annual allowance of $2,000 has 
been exhausted. The Evidence of Coverage clearly states that you are responsible for anything over the 
allowance amount. 
 
Date of Service CPT Code Billed Amount Plan Paid Your Responsibility 
3/10/2020 D9310 $100 $100 $0 
6/8/2020 D7210 $312 $312 $0 
7/8/2020 D2740 $1,391 $1391 $0 
 D2950 $294 $197 $97 
 D3320 $1,026 $0 $1,026 
TOTAL:   $2,000 $1,123 
 
Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided on July 8, 2020.  
 
Your complaint about receiving a service that you asked not to have 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on December 18, 2019, through 
December 31, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because 
these supplies were billed correctly. The Plan denied your request. The Plan says the provider billed codes that 
re identified in the OPPS Addendum B with a status indicator of Y. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, per CMS, the codes billed have a status 
indicator of Y. The means that these services are not paid under OPPS. All institutional providers other than 
home health agencies bill must to a DME MAC. Therefore, we decided that the Plan does not have to pay for 
outpatient services provided on December 18, 2019, through December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 and 80307 provided on  March 
25, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes G0480 and 80307 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records 
(signed by the ordering physician) for the billed test. Based on this information, we decided that Medicare rules 
for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0480 and 80307 provided on  March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88305, 88312) provided on May 31, 
2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology services. 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 pathology services (88305, 88312) provided 
on May 31, 2019, 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 a CT scan provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should only owe the $325 surgery 
copayment and disagree with the CT scan 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 a $225 
copayment for advanced imaging services.  
 
You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 a CT scan provided on March 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided January 
20, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that the enrollee's condition is not 
related to terminal illness and the attending provider is not employed by hospice. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the member?s terminal condition until the first day of the month following the month in which 
hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 21, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency 
department visit (99285) provided January 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery (66984) provided on February 11, 2020. 
 
You asked the Plan to pay for cataract surgery. You say that you were told the enrollee had out-of-network 
benefits. The Plan denied your request. The Plan says services must be provided by providers that are enrolled 
in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider listed on the claim is not shown to be enrolled in the 
Medicare program. Based on this information, we decided that Medicare rules for coverage of cataract surgery 
have not been met. Therefore, we decided that the Plan does not have to pay for cataract surgery (66984) 
provided on February 11, 2020.