Persius/hicric huggingface dataset:
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 July 14, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that a clerk or nurse could have 
done the same work and done it equally as good. 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 $35 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied 
to the services that were provided. 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 July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services and an EKG provided by 
a participating provider on April 22, 2020. 
 
You asked the Plan to waive the copayment for specialist services and an EKG. You say that you do not agree 
with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $35 
copayment and a $20 copayment for physician/practitioner services/in-network/specialist and outpatient 
diagnostic tests/non-radiological services.  
 
You have been asked to pay a $35 copayment for specialist services. You are being asked to pay $16.41 which 
is less than your copayment amount of $20 an EKG. The total amount you are being asked to pay is $51.41 
($35 + $16.41 = $51.41). Specialist services falls within the physician/practitioner services/in-
network/specialist benefit category and an EKG falls within the outpatient diagnostic tests/non-radiological 
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 specialist services and an 
EKG provided by a participating provider on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00812) provided on May 23, 2019. 
 
You asked the Plan to pay for anesthesia services. You say that this claim was originally filed in June of 2019. 
The Plan denied your request. The Plan says this claim was not received within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for anesthesia services was not filed until May 29, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for anesthesia services (00812) provided on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for dermatology services provided by a 
participating provider on June 22, 2020. 
 
You asked the Plan to waive the deductible for dermatology services. You say that you were told that all 
copayments were waived because of Covid-19. The Plan denied your request. The Plan says the correct 
deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible for physician/practitioner services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $150 deductible for physician/practitioner services. This cost sharing is a contractual obligation that 
had not been met at the time dermatology services was received on June 22, 2020. The total amount you are 
being asked to pay is $60.27. Therefore, we decided that the Plan does not have to waive the deductible for 
dermatology services provided by a participating provider on June 22, 2020.  
 
Please contact the Plan for verification on what cost sharing amounts are waived and what cost sharing 
amounts are not.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 29, 
2020, to February 3, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because this is the only hospital in your area. 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 $375 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from January 29, 2020, to February 3, 2020. Therefore, you are responsible 
to pay a $375 copayment for days 1-5 (January 29, 2020, to February 2, 2020). $375 (copayment) x 5 (inpatient 
days) = $1,875. 
 
You have been asked to pay the total copayment amount of $1,875 for an inpatient hospital stay. An inpatient 
hospital 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 an inpatient hospital stay from January 29, 2020, to February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 6, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you 
believed you were only responsible for the copayment. The Plan denied your request. The Plan says all services 
other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when 
ordered or performed by a doctor of chiropractic. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging (78815) provided on May 4, 2020. 
 
You asked the Plan to pay for the PET imaging. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says C18.9 is not listed as an appropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815 is not supported in the record. Specifically, per CMS diagnosis code C18.9 is not 
an appropriate diagnosis code for PET procedures performed to inform the  initial treatment strategy of tumors. 
Based on this information, we decided that Medicare rules for coverage of the PET imaging have not been met. 
Therefore, we decided that the Plan does not have to pay for PET imaging (78815) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on June 16, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you feel that the doctor did little to treat you and was rude.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 $45 copayment for specialist services.You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 fora specialist visit provided on June 16, 2020.We note your complaint that the doctor was rude and did little to treat your condition. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detection test by nucleic acid for digestive tract pathogen 
(87507) and stool culture (87046) provided on March 9, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for detection test by nucleic acid for digestive tract pathogen and stool culture. You 
say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization 
must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 detection test by nucleic acid for digestive tract 
pathogen (87507) and stool culture (87046) provided on March 9, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 30, 2019. 
 
You asked the Plan to pay for the dental services. You say that you do not feel that you should be held 
responsible for the cost share of these services. The Plan denied your request. The Plan says you had met your 
annual maximum benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,250 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on September 30, 2019 and 
your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the dental services provided on September 30, 2019.  
 
Your complaint about the issues you had with the provider 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Physician (MD) certification for Medicare-covered home 
health services under a home health plan of care (patient not present), including contacts with home health 
agency (HHA) and review of reports of patient status required by physicians to affirm the initial 
implementation of the plan of care that meets patient's needs, per certification period (G0180) provided on 
February 5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for MD certification HHA patient. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 Physician (MD) certification for Medicare-
covered home health services under a home health plan of care (patient not present), including contacts with 
home health agency (HHA) and review of reports of patient status required by physicians to affirm the initial 
implementation of the plan of care that meets patient's needs, per certification period (G0180) provided on 
February 5, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dual-energy X-ray absorptiometry (DXA) services 
provided on October 2, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the Dual-energy X-ray absorptiometry (DXA) services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are 
not a covered benefit. 
 
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 Dual-energy X-ray absorptiometry (DXA) 
services provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystoscopy (52000) provided on June 1, 
2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 in-network physician services provided at a specialists office.  
 
You have been asked to pay a $50 copayment for the physician services provided at a specialists office. 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 cystoscopy (52000) provided on June 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0428) and the ambulance mileage (A0425) provided on April 9, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 one-way ambulance trip.  
 
You have been asked to pay a $209.50 copayment for the one-way ground ambulance trip provided. This is the 
Plan allowed amount which is less than the applicable copayment for this service. 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 ambulance transportation service (A0428) and the ambulance mileage (A0425) 
provided on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 25, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 
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 lab work provided on June 25, 2020 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95999) provided on November 25, 
2019. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation indicates that train of 
four monitoring was performed which does not meet the CMS guidelines of CPT code 95999. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring does not 
meet the CMS guidelines of CPT code 95999. Additionally, train of four monitoring is considered integral to 
the primary procedure and not separately reimbursable. Based on this information, we decided that Medicare 
rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does 
not have to pay for train of four monitoring (95999) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 10, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you have never paid more 
than $35 for these before. You say that you receive injections and leave within 5 minutes. 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 $250 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $250 copayment for an outpatient surgery. The injections you received are 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery/in-network 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 outpatient surgery provided by a participating provider on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 21, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on March 9, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 office visit (99214) provided on March 9, 
2020, by an out of network (OON) provider.