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

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on 
December 31, 2019. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you were advised you 
could get your teeth cleaned at any dentist and claim up to $150 for reimbursement. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
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 periodontal scaling and root 
planing is not covered under this preventive benefit. Therefore, we decided that the Plan does not have to pay 
for the periodontal scaling and root planing provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy supplies provided on May 28, 2020. 
 
You asked the Plan to pay for the ostomy supplies. You say that you were not made aware that this provider 
was not in-network with your new health plan. 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 
ostomy supplies. We found no exception that would require the Plan to pay for these items. Therefore, we 
decided that the Plan does not have to pay for ostomy supplies provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided by a participating 
hospital on January 29, 2020 to March 16, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $435 
copayment for outpatient surgery/surgery.  
 
You have been asked to pay a $435 copayment for an outpatient surgery. The total amount you are being asked 
to pay is $1,740 ($435 x 4 visits = $1,740). Wound care is considered an outpatient surgery; therefore, the 
correct copayments have been applied. An outpatient surgery falls within the outpatient surgery/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 wound care provided by a participating hospital 
on January 29, 2020 to March 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT codes 99285 and 93010 provided on February 18, 2020. 
 
You asked the Plan to pay for CPT codes 99285 and 93010. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention 
that requires the underlying condition be sequenced first, followed by the manifestation. In this case, D63.1 is a 
manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on this 
information, we decided that Medicare rules for coverage of CPT codes 99285 and 93010 have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT codes 99285 and 93010 provided on 
February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
services is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 9, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and bitewing x-ray provided on January 
28, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and bitewing x-ray. You say that you have no money to take 
care of this. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 
intraoral x-ray and bitewing x-ray provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on February 25, 2020. 
 
You asked the Plan to pay for the consultation (D9310). You say that you were informed the dentist was a 
covered provider. You say that you were supposed to be covered 100% up to $2,000. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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 
consultation (D9310) provided on February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you were not able to 
function and so you had to have your son call for an ambulance. When the ambulance arrived, the responders 
evaluated you and noticed that you had dangerously low blood glucose levels. You say that they were able to 
stabilize you and treat you in your home. You stated that the ambulance crew did not want to take you to the 
hospital in order to prevent a Covid-19 contamination. You asked the Plan to reconsider their denial because 
the services were medically necessary. 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 May 4, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the lift chair, delivery and set up (A9901), 
and the sales tax (S9999) provided on February 5, 2020. 
 
You asked the Plan to issue reimbursement for the lift chair, delivery and set up, and sales tax. You say that 
you are requesting reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan 
says these items are not a covered benefit under your contractual policy. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment that is mainly used to 
serve a medical purpose is a covered benefit. Seat lift mechanisms are covered under the Durable Medical 
Equipment benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these items have not been met. Specifically, a lift chair does not meet the definition of durable 
medical equipment because armchairs are not primarily medical in nature. The Plan has made payment for the 
Medicare allowed amount of the seat lift mechanism.  
 
 
 
 
 
 
However, the lift chair, delivery and set up, as well as the sales tax for this non-Medicare covered item cannot 
be reimbursed as they do not fall into a covered benefit category. Therefore, we decided that the Plan does not 
have to issue reimbursement for the lift chair, delivery and set up (A9901), and the sales tax (S9999) provided 
on February 5, 2020.
Appeal type: Outpatient Mental Health
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 from January 7, 2020, to January 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
from January 7, 2020, to January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 18, 2018 to 
February 11, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the custodial care services. You say that you would like reconsideration because 
you were supposed to receive care from a provider that accepted Medicare, but they closed so you were 
released to this provider. The Plan denied your request. The Plan says except for emergency services, the plan 
cannot pay a provider who is not eligible to participate in Medicare. Additionally, custodial care is not covered 
under any condition. 
 
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 eligible to participate in Medicare. The Plan did not pre-approve the 
item/service at issue. Additionally, custodial care is not covered under any condition. 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 medical services provided on December 18, 2018 to February 11, 2019 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 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 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 service 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 out of network physician services provided to the enrollee on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided February 
14 to February 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. 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 $265 
copayment per day for days 1-7 for Inpatient Care.  
 
You have been asked to pay a $1060 copayment for 4 days of inpatient hospital care. 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 care provided February 14 to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not payable for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
24105. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgeon services provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical supplies rendered on February 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure codes A4550, A4300, and A4263 have a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the surgical supplies rendered on February 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from July 28, 2019 to 
August 2, 2019. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the 
enrollee 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 
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 physical therapy services provided from July 28, 2019 to August 
2, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on April 15, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you should not be responsible for 
the copayment because the doctor didn't help. 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 $110 
copayment for each Medicare-covered emergency room visit.  
 
Review of the file shows that you received ER services on April 15, 2020. You have been asked to pay a $110 
copayment for these services. These services fall within the Medicare-covered emergency room visit 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 emergency room (ER) services rendered on 
April 15, 2020.  
 
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tropicamide 1% ophthalmic drops, Proparacaine HCl 
0.5% ophthalmic drops and Phenylephrine ophthalmic solution provided on March 23, 2020. 
 
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not 
covered by the Plan. 
 
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 Tropicamide 1% ophthalmic 
drops, Proparacaine HCl 0.5% ophthalmic drops and Phenylephrine ophthalmic solution provided on March 
23, 2020.  
 
Benefits for these 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92004) 
refraction services (92015) dilated macular or fundus exam performed (G8397) Ophthalmic ultra-sound 
(76514) computerized ophthalmic imaging optic nerve (92133)  provided February 17, 2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that you had called the plan and 
was told by the representative that you are not responsible for this charge. The plan covers this cost so why is 
the provider billing you. The Plan denied your request. The Plan says the claim processed correctly 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 $40 
copayment for Medicare covered vision services in a specialist office.  
 
You have been asked to pay $40 copayment for the vision services. The vision services fall within the Vision 
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 comprehensive eye exam 
(92004) refraction services (92015) dilated macular or fundus exam performed (G8397) Ophthalmic ultra-
sound (76514) computerized ophthalmic imaging optic nerve (92133)  provided February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on February 27, 2020 by a 
provider that has opted out of Medicare. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and not a dental 
service. The Plan denied your request. The Plan says the provider of this service has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
an office visit (99203) provided on February 27, 2020 by a provider that has opted out of Medicare.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0426) provided 
February 15, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. 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 $325 
copayment for Ambulance Services.  
 
You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance 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 
an ambulance transport (A0426) provided February 15, 2020.