Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under 
code 99239 for dates of service October 29, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. 
This service represents a hospital discharge day management of more than 30 minutes. The documentation 
submitted does not indicate the time spent on discharge services. The submitted medical records do not support 
hospital discharge day management of more than 30 minutes was performed. It is noted that multiple attempts 
were made to contact the provider for additional information. 
 
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 records provided do not support 
the time-based services billed. Therefore, we decided that the Plan does not have to pay for physician services 
provided to the enrollee and billed under codes 99239 for dates of service October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 medical services provided to the enrollee by an out-of-network provider 
on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided 
February 18, 2020. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for diagnostic tests.  
 
You have been asked to pay the allowable amount of $19.55 as a copayment for the electrocardiogram. The 
electrocardiogram falls within the diagnostic tests benefit category. In this case, the allowed amount is less than 
the $30 copayment noted in the plan contract. 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 
electrocardiogram (93000) provided February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
rendered on July 15, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that other preventive screenings are 
covered. 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 $275 
copayment for each advanced imaging service (e.g. CT scans).  
 
Review of the file shows that you received a CT scan of the chest on July 15, 2020. You have been asked to 
pay a $275 copayment for these services. These services fall within the advanced imaging service (e.g. CT 
scans) benefit category. This service is not a preventive service that is covered at no cost by Medicare. 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 computed tomography (CT) scan rendered on July 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee and billed under code 
G0480. 
 
You asked the Plan to pay for codes 80307 and G0480. You say that this claim should be paid. The Plan denied 
your request. The Plan says while code 80307 was paid, the records provided do not support the billing of code 
G0480. The Plan says that the documentation submitted did not include a physician order/lab requisition or 
medical records stating exactly what tests are to be performed. The submitted Laboratory Requisition indicates 
that Urine Drug Screen Panel was requested. The submitted documentation does not itemize what tests are 
included in this panel; therefore, the billed code cannot be verified.  
 
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 records provided do not support 
the services billed. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided 
that the Plan does not have to pay for drug testing provided to the enrollee and billed under code G0480.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the hearing aids. 
 
You asked the Plan to make additional payment for the hearing aids. You say that this was denied, and it is not 
clear why this would not be covered due to your hearing disability. The Plan denied your request. The Plan 
says payment was made up to the maximum benefit allowance for hearing aids of $1000. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids, but coverage is limited to $1000 for a pair of hearing aids every two years.  
 
We reviewed the file. The Explanation of Benefits shows that the $1000 benefit was applied to the claim. The 
Plan is not required to make payment in excess of the $1000 maximum. Therefore, we decided that the Plan 
does not have to make additional payment for the hearing aids.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 27, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services 
provided to the enrollee on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays provided on 
March 10, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you received these 
services from an out-of-network provider, and paid for them in full. The Plan denied your request. The Plan 
says only one set of intraoral x-rays is covered per calendar year. The Plan also says that one intraoral x-ray has 
already been approved. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received three intraoral periapical x-rays on March 10, 
2020, one of which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays provided on 
March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $125 copayment for outpatient diagnostic services 
provided on April 28, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $125 
copayment for outpatient radiological services.  
 
You have been asked to pay $125 copayment for this copayment. this copayment falls within the outpatient 
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 $125 copayment for outpatient 
diagnostic services provided on April 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on March 1, 2020 to 
March 12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization is required 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 skilled nursing services provided on March 1, 
2020 to March 12, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
3, 2020 to February 7, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Type of bill ?033x? is no longer valid, effective October 1, 2013. The Plan states the 
appropriate home health data Type of Bill was not billed correctly. The Plan states a corrected claim would be 
reviewed if submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate forms. In this case, the claim submitted cannot be paid due 
to an issue with the ?Type of bill? submitted.  Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from 
February 3, 2020 to February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on April 13, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on April 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from April 14, 2020, 
through April 21, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Licensed Professional Counselor. Medicare 
says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy services provided from April 14, 2020, 
through April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services, inpatient mental 
health services and emergency care provided June 30, 2020 to July 6, 2020. 
 
You asked the Plan to waive the copayment for the emergency services, ambulance and inpatient mental health 
services. You say that you would like to appeal the claim for services. You did not authorize this behavior, 
activity or any other claim of the sort and nature of this money paid out to them The Plan denied your request. 
The Plan says the claims were processed correctly per the Evidence of Coverage. 
 
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 
copayment for transportation between inpatient facilities, $275 per day for days 1-5 $0 each day for days 6-90 
for Medicare covered stay at a network hospital, $150 copayment for each Medicare covered emergency room 
visit.  
 
You have been asked to pay $1495 for the emergency services, ambulance services and inpatient mental health 
services. The emergency services, ambulance and inpatient mental health services falls within the ambulance 
services emergency care and inpatient mental health care benefit categories. 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 services, inpatient mental health 
services and emergency care provided June 30, 2020 to July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided by a 
participating provider on June 3, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not agree with 
this copayment. 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 $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day inpatient hospital services. Inpatient hospital services 
fall 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 
inpatient hospital services provided by a participating provider on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear purchased by the enrollee on April 10, 2020. 
 
You asked the Plan to pay for this eyewear for the enrollee. You say that this eyewear should be covered by the 
Plan. The Plan denied your request. The Plan says when the claim for April 10, 2020 for frames in the amount 
of $69.22, was received, it denied because the annual benefit of $125.00 had already been paid on the claim for 
January 7, 2020. Therefore, no further payment can be made for the services received on April 10, 2020. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. Based on the records provided, the $125 allowance was exhausted prior to this purchase. Therefore, 
we decided that the Plan does not have to pay for eyewear purchased by the enrollee on April 10, 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 January 
31, 2018. 
 
You asked the Plan to waive the copayment for these services. You say that you saw a primary care provider, 
not a specialist. 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 $50 
copayment for in-network specialist visits.  
 
Review of the file shows that you received specialist services from a rheumatologist on January 31, 2018. You 
have been asked to pay a $50 copayment for these services. These services fall within the in-network specialist 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered 
on January 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating hospital on May 7, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you thought your 
copayment would be $45. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $314.74. The total amount you are being asked to pay is $62.95 ($314.74 x 20% = $62.95). 
An outpatient surgery was performed; therefore, the correct copayment has been applied. An outpatient surgery 
falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
an outpatient surgery provided by a participating hospital on May 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport 
provided on March 15, 2020. 
 
You asked the Plan to waive this service. You say that you think the copayment is too high. The Plan denied 
your request. The Plan says this copayment is a contractual obligation. 
 
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 ambulance transport. 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 $225 copayment charged for ambulance 
transport provided on March 15, 2020.