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

We decided that the Plan does not have to pre-approve surgery to be provided by the requested out-of-network 
provider. 
 
You asked the Plan to pre-approve the surgery. 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve surgery to 
be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on September 3, 2019 by 
an OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were insured at the time of service. 
The Plan denied your request. The Plan says the services were rendered by a non-network provider in a non-
participating facility. The Plan also says that you were referred by another non-participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on September 
3, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you should only owe a $35 specialist 
visit. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $295 copayment for an EGD. An EGD falls within the outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits you had on July 
6, 2020, and August 3, 2020. 
 
You asked the Plan to waive the copayments for the specialist office visits. You did not provide an argument as 
to why these copayments should be waived. The Plan denied your request. The Plan says you were charged 
these copayments correctly.  This doctor is not your selected Primary Care Provider (PCP) and this doctor is 
considered a specialist. 
 
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 $45 
copayment for specialist visits.  The doctor with whom you had these visits is a specialist. 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 specialist office visits you had on July 6, 2020, and August 3, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from March 26, 2020, to April 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you upgraded your 
plan to the Bronze Plan effective April 1, 2020.  You stated that you were originally scheduled for surgery on 
April 1, 2020, but it was rescheduled due to concerns around COVID-19.  Because you had to have your 
surgery earlier, your cost sharing is higher than it would have been under the Bronze plan.  You stated that this 
additional cost sharing is a hardship for you. 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 $350 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for the inpatient hospital services. This is 
the cost sharing that applies to the plan you were enrolled in on the dates of service.  There is no provision in 
the rules to allow for cost sharing adjustments because your surgery was moved up. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for inpatient hospital services you received from March 26, 2020, to April 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve the psychotherapy services. The Plan denied your request. The Plan says 
you do not meet medical necessity criteria for admission to out of network outpatient services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
psychotherapy services to be provided by the requested provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the 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 May 13, 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 on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided. 
 
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges 
because you have never been charged in the past. 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 $0 
copayment for lab services provided in a physician or free-standing facility and a $15 copayment for lab 
services provided in an outpatient hospital facility.  
 
The record shows that you received lab services provided at an outpatient hospital facility. 
Therefore, you are responsible to pay the $15 copayment.  
 
You have been asked to pay a $0 copayment for lab services. Lab services 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 waive the copayment 
for lab services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have dementia and are unable to 
walk on your own. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup rendered on January 24, 2020. 
 
You asked the Plan to pay for these services. You say that you would like the Plan to pay the claim. The Plan 
denied your request. The Plan says the services 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
and core buildup rendered on January 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography, transthoracic w/doppler complete 
provided on June 11, 2020. 
 
You asked the Plan to pay for the echocardiography, transthoracic w/doppler complete. The Plan denied your 
request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care 
from the effective date of election to the date of discharge or revocation. During the election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 9, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for an echocardiography, 
transthoracic w/doppler complete provided on  
June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 6, 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 procedure codes 88341 and 88364 are not covered. 
 
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 88341 is immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure). The definition of code 88364 is in situ hybridization (eg, FISH), per 
specimen; each additional single probe stain procedure (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 88341 and 88364 are not supported in the medical record. Specifically, the codes are 
add-on codes that were not billed with a required primary procedure code. 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 laboratory services rendered on March 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) received 
on April 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you received an 
Explanation of Benefits (EOB) that neglected to inform you of this copayment. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these services. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ambulance services (A0427) received on April 16, 2020.  
 
Your complaint about receiving an erroneous or misleading EOB 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 acupuncture services provided by a 
participating provider on June 15, 2020. 
 
You asked the Plan to waive the copayment for acupuncture services. You say that you have always been 
reimbursed your full $80. 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 $15 
copayment for acupuncture.  
 
You have been asked to pay a $15 copayment for acupuncture services. Acupuncture services fall within the 
acupuncture 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 acupuncture services 
provided by a participating provider on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are having a very hard time walking. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 5 specialist office visits (99211, 99215). 
 
You asked the Plan to waive the copayments for 5 specialist office visits. You say that the Plan paid in full 
previously for your international normalised ratio (INR) tests. The Plan denied your request. The Plan says the 
correct copayments were 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 $40 
copayment for each specialist visit for Medicare-covered benefits.  
 
You have been asked to pay a $40 copayment for a specialist office visit. You havebeen asked to pay a $24.73 
copayment for each of 3 specialist office visits. You have been asked to pay a $25.05 copayment for a specialist 
office visit. Specialist office visits fall within the "Physician/Practitioner Services, including Doctor?s Office Visits" 
benefit category. This means that you have been asked to pay less than or equal to 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 5 specialist office 
visits (99211, 99215) .
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941, 98943) 
provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you were not aware prior 
authorization was necessary. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider; therefore, payment has been correctly denied. 
 
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 chiropractic manipulative treatment (98941, 
98943) provided by an out of network (OON) provider.
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 April 11, 2020, to June 22, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were told there 
would be a $250 copayment. 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 10% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 10% coinsurance of the allowed amount for durable medical equipment. The 
total amount you are being asked to pay is $54.72. Durable medical equipment falls within the durable medical 
equipment/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 coinsurance for durable 
medical equipment provided by a participating provider on April 11, 2020, to June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services you received on 
March 13, 2020. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you would like these 
charges reviewed because you think you are having multiple premiums charged to you. 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 $25 
copayment for specialist services.  
 
You have been asked to pay a $25 copayment for the podiatry services. The podiatry services fall within the 
specialist 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 podiatry services 
you received on March 13, 2020.  
 
Your complaint about being double-billed for premiums 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services rendered. 
 
You asked the Plan to pay for these services. You say that the Plan should pay for the services. The Plan denied 
your request. The Plan says the claim was processed correctly. 
 
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. The Plan covers these services 
from an out-of-network provider up to the allowed amount. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid the claim from the out-of-network 
provider up to the allowed amount. Further payment is not covered by Medicare or your supplemental benefit 
with the Plan. Therefore, we decided that the Plan does not have to pay for the dental services rendered.