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

We decided that the Plan does not have to pay for the Revita autograft rendered on December 13, 2019. 
 
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 services are experimental/investigational in nature and not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had osteonecrosis of the 
mandible with wound dehiscence. The use of Revita to treat the enrollee's condition is currently considered 
experimental/investigational in nature. The services were therefore not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. 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 Revita autograft rendered on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicament provided on 
June 12, 2020. 
 
You asked the Plan to pay for the application of desensitizing medicament. You say that you were told that this 
provider was in-network, and you would be covered. You also say that the bill shows the provider was out-of-
network, and it cost you more. The Plan denied your request. The Plan says this service is not covered. 
 
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 
application of desensitizing medicament provided on June 12, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that the endoscopy should have been 
done while you were in the hospital. You say that you shouldn't have to pay this copayment. 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 $350 per 
day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, 
and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the "Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit 
category. The records show that the endoscopy was performed as an outpatient procedure. 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 endoscopy provided on July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided by Genesis Reference 
Laboratories, on June 11, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you were not feeling well and did not want 
to go to your medical center. You say that it was easier to get the services in your condominium because you 
believed it was covered by your insurance. The Plan denied your request. The Plan says you must receive care 
from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of 
the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan.   
 
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 
laboratory services. 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 laboratory services provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that that observation status would have been 
appropriate for this episode. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The 
record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier emergency department and/or observation care) would span 
two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute 
inpatient hospital care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient hospital care have been met. Therefore, we decided that the 
 
 
Plan has to pay for the acute inpatient hospital care provided to the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 19, 2020, to July 19, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you don't know why 
there are two $45 charges. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 10% coinsurance for durable medical equipment.  
 
The enrollee has been asked to pay a 10% coinsurance of the allowed amount for durable medical equipment. 
The total allowed amount is $900. The total amount you are being asked to pay is $90 ($900 x 10% = $90). 
Durable medical equipment falls within the durable medical equipment benefit category. 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 upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for durable medical equipment provided by a participating provider on 
June 19, 2020, to July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with removal of toenail bed 
(99213, 11721) provided. 
 
You asked the Plan to waive the copayment for the office visit with removal of toenail bed. You say that you 
believe that copayments have been waived until the end of the year. 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 $40 
copayment for physician/practioner services.  
 
You have been asked to pay a $40 copayment for the office visit with removal of toenail bed. The service 
provided falls within the physician/practioner services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the office visit with removal of toenail bed (99213, 11721) provided.  
 
Your complaint about the customer service you received from the Plan 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 copayment for the office visit you had with your primary 
care doctor on February 18, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical, so 
there should be no copayment. The Plan denied your request. The Plan says the doctor's office confirmed this 
was not a preventive visit and it was not billed as an annual physical.  That is why the copayment 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 $10 
copayment for physician visits.  
 
You have been asked to pay a $10 copayment for the office visit. The billing records from this visit indicate 
that you did not have an annual physical but rather a regular office visit with your doctor. Annual physicals 
require certain procedure codes and diagnosis codes to be billed.  That was not the case here. 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 office visit you had with your primary care doctor on February 
18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care evaluation and management services provided. 
 
You asked the Plan to pay for critical care services. You say that these codes are payable as billed. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not support the codes 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 documentation does not 
support that these critical care services were 30 to 74 minutes in duration. Based on this information, we 
decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that 
the Plan does not have to pay for critical care evaluation and management services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical 
x-ray, additional intraoral periapical x-ray, bitewings, four periodontal scalings and root planings, and 
periodontal maintenance provided from January 24, 2020, to June 8, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewings, 
scalings and planings, and periodontal maintenance. You say that you contacted the Plan and were told that you 
could see this provider. You also say that you were not made aware that this provider was OON. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
services done by an OON dentist are not covered. 
 
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 
covered when they are received OON. The Plan confirmed that there were no calls made to the Plan prior to 
these services being rendered from you or the provider to check the provider's network status. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-
ray, additional intraoral periapical x-ray, bitewings, four periodontal scalings and root planings, and periodontal 
maintenance provided from January 24, 2020, to June 8, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided by on June 24, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that in most 
cases the care the enrollee receives from an out-of-network provider will not be covered. 
 
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 
laboratory services. 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 laboratory services provided on June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided and inpatient hospital care 
provided. 
 
You asked the Plan to waive the copayments for physical therapy and inpatient care. You say that you were not 
aware there would be high copays in this Plan. The Plan denied your request. The Plan says the cost share 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 $40 
copayment for Outpatient Rehabilitation Services and a $375 copayment for Inpatient Hospital care per day, 
days 1-5.  
 
You have been asked to pay four $40 copayments for therapeutic procedures on dates of services. You 
have been asked to pay $27.04 out of the 
$40 copayment for therapeutic procedures on date of service February 12, 2020 and $12.96 out of the $40 
copayment for physical therapy evaluation. These services fall within the 
Outpatient Rehabilitation Services benefit category. You have also been asked to pay two $375 copayments for 
inpatient care per day 1-5. This service falls within 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 copayments for physical therapy provided.  
 
Your complaint about potentially being misinformed 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 copayment for an outpatient surgery provided by a 
participating provider on May 12, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were never told you 
would owe this much. 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 $395 
copayment for outpatient surgery/in-network/surgery.  
 
You have been asked to pay a $395 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network/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 copayment for 
an outpatient surgery provided by a participating provider on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the otolaryngology (ENT) visit you had on 
July 27, 2020. 
 
You asked the Plan to waive the copayment for the ENT visit. You say that this was a follow-up visit, so there 
should be no charge. The Plan denied your request. The Plan says you were charged this copayment 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 $40 
copayment for specialist office visits.  
 
You have been asked to pay a $40 copayment for the ENT visit. The ENT visit falls within the specialist office 
visits benefit category. There is no provision in your contract that states that copayments for follow-up visits 
are waived. 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 otolaryngology (ENT) visit you had on 
July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgical services provided to the enrollee on 
January 21, 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 Medicare cannot reimburse a surgical assistant's services if the assistant is an unlicensed 
practitioner and does not qualify to be a Medicare provider. 
 
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 assistant surgical services provided 
to the enrollee on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine procedure you had at 
an outpatient hospital facility on June 22, 2020. 
 
You asked the Plan to waive the copayment for the nuclear medicine procedure. You say that you already paid 
a copayment for the CT scan you had on that date, so you don't think you should have another copayment. The 
Plan denied your request. The Plan says you had two separate services, so two separate copayments were 
charged appropriately. 
 
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 
copayment for diagnostic procedures and tests performed in an outpatient hospital facility.  
 
Records show that on June 22, 2020, you had both a CT scan and a nuclear medicine procedure at the hospital.  
You were charged separate copayments for each service. You have been asked to pay a $20 copayment for the 
nuclear medicine procedure. The nuclear medicine procedure falls within the diagnostic procedures and tests 
performed in an outpatient hospital facility 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 nuclear medicine procedure you had at an outpatient hospital facility on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 30, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says in most 
cases the care the enrollee receives from an out-of-network provider will not be covered. 
 
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 
laboratory services. 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 laboratory services provided on June 30, 2020.