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

We decided that the Plan does not have to reduce the cost share for the CT scans and contrast material provided
on February 19, 2020.
You asked the Plan to reduce the cost share for the CT scans and the contrast material. You say that you were
not informed that you would have two copayments for two areas of the body. You say you would not have had
the second CT scan. The Plan denied your request. The Plan says you have been charged the correct cost
sharing 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 $150
copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays,
performed in a physician's office or at a free-standing facility (such as a radiology center or medical center) and
20% coinsurance for each in-network Medicare-covered medical supply.
You have been asked to pay a $150 copayment for each of the CT scans. You have also been asked to pay
$41.09 which is 20% of the allowed amount for the contrast material. The allowed amount is $205.43. ($205.43
x 20% = $41.09). ($150 + $150 + $41.09 = $341.09). The CT scans and the contrast material fall 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 reduce the cost share for the CT scans and contrast material provided on February 19,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on March 7, 2020.

You asked the Plan to reduce the copayment for the urgent care visit. You say that this was a regular office visit and an urgent visit. The Plan denied your request. The Plan says the claim was reprocessed and the copayment was reduced to a $20 copayment as a one-time exception.

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 $65 copayment for each Medicare-covered urgent care facility visit. 

You have been asked to pay a $20 copayment, which is less than the standard copayment, for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 reduce the copayment for the urgent care visit provided on March 7, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bronchoscopy provided by a participating
provider on February 24, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these
charges. 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 $315
copayment for outpatient surgery/in-network.
You have been asked to pay a $315 copayment for an outpatient surgery. A bronchoscopy is 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 a
bronchoscopy provided by a participating provider on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for wrist hand finger orthosis (L3807) provided on December 31, 2019. 
 
You asked the Plan to pay for wrist hand finger orthosis. You say that you would like reconsideration because 
replacement due to loss is approved and acceptable. The Plan denied your request. The Plan says that this claim 
was billed more than the frequency allowance. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wrist hand finger orthosis have been met. Specifically, the record clearly indicates that this is a 
replacement due to loss. Replacement is acceptable in cases due to loss or irreparable damage. Therefore, we 
decided that the Plan has to pay for wrist hand finger orthosis (L3807) provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87624) and the screening 
cytopathology (G0145) rendered by the out of network (OON) provider on December 27, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the 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 laboratory service (87624) and the screening cytopathology (G0145) rendered by 
the out of network (OON) provider on December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the extraction, bone replacement graft 
for ridge preservation, three gingival irrigations, guided tissue regeneration, three adjunctive procedures, and 
four periodontal scalings and root planings provided on December 16, 2019 
 
You asked the Plan to make additional payment for the extraction, bone replacement graft, gingival irrigations, 
guided tissue regeneration, adjunctive procedures, and scalings and planings. You say that you would like these 
charges looked into. The Plan denied your request. The Plan says extraction, bone replacement graft for ridge 
preservation, gingival irrigation, guided tissue regeneration, and unspecified adjunctive are not covered 
benefits. The Plan also says that you were correctly charged for the covered services, and signed a treatment 
plan acknowledging zero plan payment and accepting responsibility for the cost of the services rendered. 
 
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, extraction, bone replacement graft for 
ridge preservation, gingival irrigation, guided tissue regeneration, and unspecified adjunctive procedure are not 
among those covered under this benefit. The contract also clearly states that you are responsible for an $85 
copayment for each periodontal scaling and root planing. Therefore, we decided that the Plan does not have to 
make additional payment for the extraction, bone replacement graft for ridge preservation, three gingival 
irrigations, guided tissue regeneration, three adjunctive procedures, and four periodontal scalings and root 
planings provided on December 16, 2019
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the skin graft procedures provided from 
February 11, 2020 to March 26, 2020. 
 
You asked the Plan to waive the copayments for the skin graft procedures. You say that these procedures were 
not surgical and the enrollee should not have copayments. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $175 
copayment for in-network outpatient surgery services.  
 
You have been asked to pay a $175 copayment for the skin graft procedure on each date of service. The skin 
graft procedures fall within the Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers benefit category. The record shows the skin graft procedures are considered 
skin replacement surgeries. 
 
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 the skin graft procedures provided from February 11, 2020 
to March 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on March 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer any 
medications while you were in the hospital. The Plan denied your request. The Plan says self-administered 
drugs are not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on March 10, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on February 21, 2020.
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the radiology 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 radiology services provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated knee orthosis (L1832) provided on May 1, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the orthosis. You say that please see the attached medical documentation and 
process the claim for payment. The knee brace is medically necessary for the enrollee. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-
emergent services with non-contracted providers require prior-authorization prior to services being rendered. 
 
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 prefabricated knee orthosis (L1832) provided 
on May 1, 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 hearing aids purchased on February 25, 2020 from a non-
participating provider. 
 
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says you exhausted your benefit allowance. 
 
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.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. You exhausted your benefit allowance, because the Plan 
reimbursed you $1200 for the services. Your EOC states that enrollees must pay any amount over $600 per ear, 
per year. Therefore, you are responsible for the remainder of the costs. Therefore, we decided that the Plan 
does not have to pay for the hearing aids purchased on February 25, 2020 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trigger point injection (CPT 20553) provided to the enrollee 
on February 24, 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 Current Procedural Terminology (CPT) code 20553 (1 unit) remains not supported. 
 
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 20553 is "Injection(s); single or multiple trigger point(s), 
3 or more muscles." 
 
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 
prescriber submitted medical records. The records do not support that 3 or more muscles were injected. The 
record states that the procedure was, "Trigger point injection. (sic)" Singular, not plural. The record also states 
that a single injection was made into the area of maximal tenderness. The Current Procedural Terminology 
(CPT) code 20553 is not supported. 
 
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 trigger point injection (CPT 20553) provided to the enrollee on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the inhalation of nitrous oxide/analgesia (D9230) and two removals of residual tooth roots (D7250 x2) provided on October 10, 2019.
You asked the Plan to pay more for the inhalation of nitrous oxide/analgesia and removals of residual tooth roots. You say that you were told that the Plan paid their part of the services. You also say that you were told the Plan was charging too much. The Plan denied your request. The Plan says inhalation of nitrous oxide/analgesia is not a covered benefit under your dental plan. The Plan also says that copayments are contractual obligations and cannot be waived.
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, inhalation of nitrous oxide/analgesia is not among those covered under this benefit. The Plan confirmed that you signed a treatment plan showing no coverage for the nitrous oxide, and accepting responsibility for the cost. The contract also clearly states that you are responsible for a $90 copayment for the removal of residual tooth roots (D7250). Therefore, we decided that the Plan does not have to pay more for the inhalation of nitrous oxide/analgesia (D9230) and two removals of residual tooth roots (D7250 x2) provided on October 10, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the upper and lower 
extremities provided on March 3, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you are not supposed to receive a 
bill for services done in your PCP's office. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $25 
copayment for carotid or peripheral vascular ultrasound.  
 
You have been asked to pay a $25 copayment for the ultrasound. The ultrasound 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 the ultrasound of the upper and lower extremities provided on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided January 23, 2020. 
 
You asked the Plan to pay for the initial observation care. You say that CMS guidelines do allow for a separate 
charge in this instance since the physicians were of different specialties. Please review the attached 
documentation for reprocessing of the denied service. The Plan denied your request. The Plan says this claim 
processed correctly as the supporting documentation only supports one initial observation code being 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that an initial observation care evaluation and management service was reported and processed for the 
same date of service by the same provider under a different claim. No documentation was received supporting 
a different physician saw the enrollee. This code can only be billed once per day. Based on this information, we 
decided that Medicare rules for coverage of the initial observation care have not been met. Therefore, we 
decided that the Plan does not have to pay for initial observation care (99220) provided January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) and 
neuromuscular stimulator, electronic shock unit (E0745) provided February 26, 2020. 
 
You asked the Plan to pay for the orthoses and electronic shock unit. You say that please see the attached 
documentation to prove medical necessity. The Plan denied your request. The Plan says all information was 
provided over the phone, no actual treatment records were provided to substantiate the enrollee's orally 
reported medical history, there is no evidence of an established relationship between the enrollee and the 
ordering physician, there was no claims submitted for an evaluation and management service and there is no 
evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.  
 
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 the knee orthosis (L1851) suspension sleeve 
(L2397) and neuromuscular stimulator, electronic shock unit (E0745) provided February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on February 28, 
2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you do not agree with the surgical 
charges and believe that you should only owe a $50 copayment. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient surgery.  
 
The record shows that you received arthrocentesis on February 28, 2020 at an outpatient hospital facility. 
Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $225 
copayment.  
 
You have been asked to pay a $225 copayment for arthrocentesis. Arthrocentesis 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 copayment for arthrocentesis provided on 
February 28, 2020.