Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on May 9, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you believed your molar had been cracked, and required a visit to a dentist for emergency 
treatment. The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan 
also says that you did not elect to purchase a supplemental dental benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on May 
9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on March 17, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment you are being charged 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 $100 
copayment for in-network CT scans.  
 
You have been asked to pay a $100 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 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 13, 
2020 to April 16, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had to be 
readmitted to the hospital and feel that you should not be charged a second 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 $250 
copayment for each hospital stay until discharge for inpatient hospital care.  
 
You had an inpatient hospital stay from April 13, 2020 to April 16, 2020. This is considered a new inpatient 
hospital stay. Therefore, you are responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment 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 April 13, 2020 to April 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 28, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on 
February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on January 27, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with this copayment. 
The Plan denied your request. The Plan says the correct copayment amount 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 
copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay $17.94 which is less than your copayment amount of $20 for an x-ray. an x-ray 
falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by a participating provider on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for various services received from March 5, 
2020 to March 10, 2020. 
 
You asked the Plan to waive the cost-sharing for the services. You say that  The Plan denied your request. The 
Plan says the total cost-share 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 20% 
coinsurance for Medicare-covered medical supplies. 
 
At the outset of the services at issue in this case, you still had $819.05 left from your deductible. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
The services received on March 5, 2020 (CPT 99204, 93000, 93006, 93880, 93224) all tracked towards the 
deductible, leaving a remainder of $39.62 on the deductible, with a total of $779.43 paid towards the deductible 
on this case. 
 
You received a preventive ultrasound on March 5, 2020 as well, which was not subject to the deductible, and 
was rather subject to a 50% coinsurance ($69.58), as the services were received out-of-network. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
You have been asked to pay 20% coinsurance ($53.40) for the chemical agents received on March 6, 2020 
(HCPCS A9502). These services falls within the Medicare-covered medical supplies benefit category. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
Additionally, on March 10, 2020, CPT 96374 was received (injection of drug or substance into the vein for 
therapy, diagnosis or prevention). This service was provided by a specialist, which typically garners a 
copayment of $50. However, the allowed amount was $48.44, so you owe that lower amount instead. 
 
The total cost-sharing applied on this claim - $950.85 - is supported by the case file and Evidence of Coverage. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to waive the cost-sharing for various services received from 
March 5, 2020 to March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (CPT 64492) provided to the enrollee on 
February 4, 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 CPT 64492 is not supported by the medical records submitted. 
 
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 64492 is "injection(s) of a diagnostic or therapeutic 
agent, into a cervical or thoracic paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) 
with image guidance (fluoroscopy or CT), for the third and any additional level(s) (listed separately in addition 
to code for primary procedure)." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
medical records provided do not include sufficient documentation to support an injection(s) of a diagnostic or 
therapeutic agent, into a cervical or thoracic paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), for the third and any additional level(s) (listed separately 
in addition to code for primary procedure) being performed on February 4, 2020, therefore this service cannot 
be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services (CPT 64492) provided to the enrollee on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 4, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not covered for screening purposes. 
 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 4, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on December 22, 
2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the copayment should 
be waived because the enrollee was admitted to a hospital the same day she was seen in the emergency room. 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency services. The contract also says that enrollees do not pay the 
emergency room visit cost-share if admitted to the hospital within 24 hours for the same condition. 
 
In this case, however, the enrollee was transferred and admitted to a different hospital than where the 
emergency room visit took place. Therefore, the enrollee has been asked to pay a $90 copayment for an 
emergency room visit. An emergency room visit falls within the "Emergency care" 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 copayment for an emergency room visit on December 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 24, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these tests were ordered by 
telemedicine which is a Medicare prohibited action and the tests were performed for screening purposes. 
 
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 laboratory testing provided 
on January 24, 2020.
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 September 26, 2019. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. 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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $2,899.50. The total amount you are being asked to pay is $579.90 ($2,899.50 x 20% = 
$579.90). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you on February 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 you on February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TMVR provided on March 13, 2020. 
 
You asked the Plan to pay for the TMVR. You say that you would like reconsideration because this service was 
medically necessary. The Plan denied your request. The Plan says a valid clinical trial number from the 
CMS.gov TMVR list of clinical study approvals was not billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS covers TMVR for MR under CED. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TMVR have not been met. Specifically, the submitted claim has not been billed with a valid 
clinical trial number. Therefore, we decided that the Plan does not have to pay for TMVR provided on March 
13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 88341) provided on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was 
not billed with a primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that add-on codes can only be reported in addition to 
a primary procedure. When the CPT Manual identifies specific primary codes, the add-on code shall not be 
reported as a supplemental service for other HCPCS/CPT codes not listed as a primary code. CPT code 88341 
is an add-on code and was not billed with an appropriate primary code. Therefore, we decided that the Plan 
does not have to pay for the services (CPT 88341) provided on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 18, 2019.

You asked the Plan to pay for the service. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for home and outpatient international 
normalized ratio (INR) monitoring services provided March 13, 2020 to May 8, 2020. 
 
You asked the Plan to waive the copayment for the outpatient INR monitoring services. You say that you are 
retired and on a set budget which makes you unable to pay for this service. Your other insurance policy in the 
past paid for the doctor to read your blood work results. The Plan denied your request. The Plan says the claim 
processed correctly and the correct copayment was applied per the plan benefits. 
 
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 $15 
copayment for services obtained from a specialist, or under circumstances, treatment by a nurse practitioner or 
physician's assistant or other non-physician health care professionals in a specialist's office.  
 
You have been asked to pay $42.63 for the outpatient INR monitoring services. The plan however instead of 15 
has charged $10.68 for each day. The outpatient INR monitoring services 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 
for home and outpatient international normalized ratio (INR) monitoring services provided March 13, 2020 to 
May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis procedure provided on December 2, 2019. 
 
You asked the Plan to pay for the dialysis services (90945). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the billed service 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 CPT Code Manual definition of code 90945 is Dialysis procedure other than hemodialysis (eg, 
peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a 
physician or other qualified health care professional.  
 
We find that CPT code 90945 is not supported in the medical record. Specifically, the medical records 
submitted do not show this procedure was done on December 2, 2019. Based on this information, we decided 
that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan 
does not have to pay for the dialysis procedure provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on April 23, 2019. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says there is no coverage if 
frames and anti-reflective coating are received from a provider not part of the Plans vision vendor network. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by the Plan's vision vendor. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear was not provided by the Plan's 
vision vendor. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not 
been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on April 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of a spinal neurostimulator (63661) provided on 
January 28, 2020. 
 
You asked the Plan to pay for the removal of a spinal neurostimulator. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the MUE value 
set for CPT code 63661 is 1 units of service and has a MUE adjudication indicator equal to 1 for an absolute 
date of service edit. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 63661 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the removal of a spinal neurostimulator have 
not been met. Therefore, we decided that the Plan does not have to pay for the removal of a spinal 
neurostimulator (63661) provided on January 28, 2020.