Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation provided from 
February 1, 2019, through March 31, 2019. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you were told you would 
have one $50 copayment not $50 per session. You say that you may not have done the sessions if you knew the 
cost. The Plan denied your request. The Plan says the copayments 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 $50 
copayment for Medicare-covered cardiac rehabilitation services from an in-network provider. 
 
You have been asked to pay a $50 copayment for each cardiac rehabilitation visit. Cardiac rehabilitation falls 
within the "Cardiac rehabilitation 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 cardiac rehabilitation provided from February 1, 2019, through March 31, 2019.  
 
Your complaint about receiving inaccurate information 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 deductible for the office visit provided on June 2, 2020. 
 
You asked the Plan to waive the deductible for the office visit. You say that you didn't know the provider was 
out-of-network. You say that you can't pay the bill. The Plan denied your request. The Plan says the deductible 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost for most of your covered services. Out-of-network services are not excluded from 
the deductible.  
 
The item or service you asked the Plan to waive the copayment for falls within the "Physician/Practitioner 
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $1,000 deductible applies to the out-of-network office visit. This cost 
sharing is a contractual obligation that had not been met at the time the office visit was received on June 2, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S0028) provided on June 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S0028 is assigned a status indicator of "I" under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 the 
services (S0028) provided on June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 10, 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 cardiovascular risk assessment is not covered in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules specifically state this type of 
testing is not covered. Therefore, we decided that the Plan does not have to pay for lab services provided to the 
enrollee on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 29, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
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. 
 
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 a domiciliary or rest home visit provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations bilateral L2-5 (64635). 
 
You asked the Plan to pre-approve radiofrequency ablations. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says this request exceeds the 
allowed Medicare amount of radiofrequency sessions reimbursed in any rolling 12 month year. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that a first diagnostic MBB (medial branch nerve 
block) bilateral L2-5 was performed on 08/11/2020 and a second MBB (medial branch nerve block) bilateral 
Lumbar L2-5 was performed on 10/08/2020. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations bilateral L2-5 (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open or surgical arthroscopic procedures on 
knee joint (01402) provided June 3, 2020. 
 
You asked the Plan to pay for the anesthesia. You say that you are sending records to support. Please reprocess 
the claim. The Plan denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 127 units of CPT code 01402 are not supported in the medical record. The plan had made multiple 
attempts to obtain additional information from the provider without success. The medical record only supports 
127 units of CPT code 01402. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for open 
or surgical arthroscopic procedures on knee joint (01402) provided June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on August 
4, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you received a letter from 
the Plan stating that copayments were 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 $45 
copayment for each specialist visit for Medicare-covered services. 
 
The Plan has waived cost-sharing for in-network primary care doctor visits for in-office, clinics, or in-home 
visits; for in-network outpatient, non-facility based behavioral health visits; and for in-network telehealth or 
virtual visits with primary care, specialty, and behavioral health providers. We noted that cost-sharing has not 
been waived for non-telehealth, in-person visits with a specialist. You have therefore been asked to pay a $45 
copayment for a specialist office visit. A specialist office visit 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 a 
specialist office visit (99213) on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP supplies (A7038, A7039) provided 
May 6, 2020. 
 
You asked the Plan to waive the coinsurance for the supplies. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing 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 20% 
coinsurance for Durable Medical Equipment and Supplies.  
 
You have been asked to pay a 20% coinsurance for the supplies. The supplies falls within the Durable Medical 
Equipment 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 coinsurance for CPAP 
supplies (A7038, A7039) provided May 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided from March 5, 
2019, through March 11, 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 claim was resubmitted untimely and 
therefore is not payable. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for inpatient psychiatric services was not filed until May 27, 2020. 
This means that more than one calendar year from the date of service had passed before a valid claim was filed. 
Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided from 
March 5, 2019, through March 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts 
 
 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a history of foot amputation, foot ulceration, peripheral 
neuropathy with calluses, foot deformity, and poor circulation of either foot. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found it appears that the medical documentation does not support the necessary guidelines for coverage of 
diabetic shoes and custom diabetic insoles. Although you do have a diagnosis of diabetes with hyperglycemia, 
there?s no medical documentation that advises that you meet any of the coverage guidelines including a history 
of foot amputation, a history of foot ulceration, diabetic neuropathy of the lower extremity, foot deformity, or 
diminished lower extremity circulation. 
 
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 pre-approve diabetic shoes and inserts
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 12, 
2019. 
 
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 the denied codes remain 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. 
 
We find that the denied CPT codes are not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 laboratory services provided to the 
enrollee on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement crown for tooth #19. 
 
You asked the Plan to pre-approve the crown. You say that you feel that this should be covered because your 
crown broke. You are not able to go without this crown because you have diabetes, and it puts you at risk of 
further decay/infection. The Plan denied your request. The Plan says you had a crown covered for this tooth in 
the last five years. As such, a replacement crown cannot be covered at this time. 
 
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 replacement of this crown may be appropriate, coverage for crowns is limited to one crown per tooth 
every five years. Records show that a crown was covered for this tooth on August 10, 2017. As such, 
replacement is not covered under the provisions of your dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve a replacement crown for tooth #19.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating ambulatory center on July 20, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were told that you 
would not owe a thing. 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 $300 
copayment for outpatient surgery/in-network/ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network/ambulatory surgical center benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an outpatient surgery provided by a participating ambulatory center on July 20, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implant and retainers rendered on June 1, 2020. 
 
You asked the Plan to pay for these services. You say that you received phone approval for these services. 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. The Plan reviewed your call history and could not locate any call in 
which you were given approval for the services. Therefore, we decided that the Plan does not have to pay for 
the dental implant and retainers rendered on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on July 20, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have a friend on the same policy 
and they didn't have to pay a copayment.  You say this bill is inaccurate. The Plan denied your request. The 
Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this 
test ($131.37) is less than your copayment obligation, you are responsible for the full 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 diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the diagnostic 
radiology 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 computed 
tomography (CT) scan of the chest you had on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery services you received at an 
outpatient hospital facility on July 21, 2020. 
 
You asked the Plan to waive the copayment for the surgery services. You say that this was an emergency 
surgery from a prior surgery, so you shouldn't have to pay a copayment. 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 $400 
copayment for outpatient hospital surgery services.  
 
You have been asked to pay a $400 copayment for the surgery services. This copayment applies regardless of 
the reason for the surgery. 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 surgery services you 
received at an outpatient hospital facility on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 31, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you cannot afford the charges. 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 $100 
copayment for ultrasounds.  
 
You have been asked to pay a $100 copayment for an ultrasound. An 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 an ultrasound provided on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator 
provided on June 15, 2018, July 15, 2018 and August 15, 2018. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that the claims 
summary reads the provider accepts insurance payment in full. You say that that is misleading, and you 
shouldn't have coinsurance. The Plan denied your request. The Plan says the coinsurance 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 durable medical equipment after the deductible is met.  
 
You have been asked to pay a total of $1,694.41 for the automatic external defibrillator.  
 
Date of Service Equipment Allowed Amount Coinsurance Member Liability 
June 15, 2018 Defibrillator $2,083.47 20% $560.69 
July 15, 2018 Defibrillator $2,834.31 20% $566.86 
August 15, 2018 Defibrillator $2,834.31 20% $566.86 
TOTAL:    $1,694.41 
 
  
 
 
The automatic external defibrillator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the automatic external 
defibrillator provided on June 15, 2018, July 15, 2018 and August 15, 2018.