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

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on November 11, 2019. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you have been trying to get a 
return on your over payment. You say that you are frustrated with customer service who do not seem to 
understand the problem. The Plan denied your request. The Plan says the correct copayment amount has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for outpatient rehabilitation services/in-network.  
 
You have been asked to pay is $5.99 which is less than your copayment amount of $15 for physical therapy. 
The correct copayment has been applied to the services that were provided. Physical therapy falls within the 
outpatient rehabilitation services/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 physical therapy provided by a participating provider on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a PET/CT scan provided on March 2, 
2020. 
 
You asked the Plan to pay for the PET scan interpretation. You say that this is billed correctly and should be 
paid. The Plan denied your request. The Plan says the claim was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes. 
 
Using the unspecified site diagnosis code, C85.10, is not appropriate based on the Medicare rules. Therefore, 
we decided that the Plan does not have to pay for the interpretation of a PET/CT scan provided on March 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 1, 2020 by a provider that 
opted out of Medicare. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says you self-referred to a provider who has opted out of the 
Medicare program. 
 
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 
the services provided on April 1, 2020 by a provider that opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided from January 2, 
2019 to December 11, 2019. 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you 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 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 out of network physician services provided from January 2, 2019 
to December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
April 6, 2020. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that you had an abscessed tooth, but 
there had to be a separation process before the extraction. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed 
partial denture sectioning (D9120) provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
January 27, 2020. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the records provided do not support the services billed and 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 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 out of network lab services provided to the enrollee on January 
27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on January 22, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that these 
services should be covered at 50% per the Plan benefits listed in your guide. The Plan denied your request. The 
Plan says the OON liability was applied correctly per your plan 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, you are responsible for the difference 
between the billed amount and allowed amount for services rendered by an OON provider. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on January 22, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on 
April 22, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you disagree with 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 $155 
copayment for ultrasounds.  
 
You have been asked to pay a $155 copayment for an ultrasound of the heart. An ultrasound of the heart 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 of the heart provided on April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the tubing, used with suction pump, the 
tracheostomy tube collar/holder, the oropharyngeal suction catheter and the tracheostomy/laryngectomy tube 
provided from March 20, 2020 through March 31, 2020. 
 
You asked the Plan to waive the coinsurance for these items. You say that you do not agree with your 
responsibility for these items. The Plan denied your request. The Plan says that these claims processed 
according to your benefit. 
 
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 (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for these items. These items fall 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 tubing, used with suction pump, the tracheostomy tube collar/holder, the oropharyngeal suction catheter 
and the tracheostomy/laryngectomy tube provided from March 20, 2020 through March 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on February 20, 2020 to May 1, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you did not have to 
pay for this before. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $1,766.25. The total amount you are being asked to pay is $353.25 ($1,766.25 x 20% = 
$353.25). Durable medical equipment and medical supplies falls within the durable medical equipment benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on February 20, 2020 to May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $20 copayment charged for specialist services provided on 
May 12, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 
copayment for specialist services. 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 $20 copayment charged for specialist services 
provided on May 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits (99214) on 
February 3 and February 4, 2020, and physical therapy (97110) received from February 13 to March 16, 2020. 
 
You asked the Plan to waive the copayments for specialist office visits and physical therapy. You say that the 
Plan should reconsider these copayments. 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 $35 
copayment for physician specialist services. The contract also clearly says that you must pay a $40 copayment 
for Medicare-covered physical therapy and speech therapy service. 
 
You have been asked to pay a $35 copayment for each one of 2 specialist office visits and a $40 copayment for 
each of 12 physical therapy sessions. Specialist office visits fall within the "Physician/Practitioner services, 
including doctor's office visits" benefit category. Physical therapy on an outpatient basis falls within the 
"Outpatient 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 copayments for 
specialist office visits (99214) on February 3 and February 4, 2020, and physical therapy (97110) received 
from February 13 to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
February 14, 2020 billed with code 99244. 
 
You asked the Plan to pay for the EM services as billed. You say that these services should be covered. The 
Plan denied your request. The Plan says the lab test was approved for payment; however, code 99244 is not 
payable by Medicare. 
 
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 CPT code 99244 has a status indicator of "I" in the Physician Fee Schedule which means it is 
invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
EM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management (EM) services provided on February14, 2020 billed with code 99244.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth specialist visit (99213) on April 
27, 2020. 
 
You asked the Plan to waive the copayment for a telehealth specialist visit. You say that you needed a 
telehealth visit due to the coronavirus pandemic. 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 $25 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $25 copayment for a telehealth specialist visit. A telehealth specialist 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 telehealth specialist visit (99213) on April 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided by an out-of-network provider on 
March 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no indication that this was completed for urgent/emergent reasons. 
 
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 imaging services provided by an out-of-network 
provider on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 4, 2020 by a non-
participating provider. 
 
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 were rendered by a non-participating 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 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 medical services provided on March 4, 2020 
by a non-participating provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for debridement (11042) provided on November 20, 2018. 
 
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that CPT code 11042 has already been paid 
under a separate claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not forwarded evidence that CPT code 11042 has been paid. 
Therefore, we decided that the Plan has to pay for debridement (11042) provided on November 20, 2018.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on June 5, 2018 
through July 26, 2018. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Medicare. 
 
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 CPT code S9328 is not supported in the record. Specifically, CPT code S9328 has a status 
indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for home infusion therapy (S9328) provided on June 5, 2018 through 
July 26, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammography (77066) and 
the diagnostic digital breast tomosynthesis (G0279) provided on January 14, 2020. 
 
You asked the Plan to waive the copayment 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 copayment 
has been applied correctly to the services provided. 
 
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 
copayment for most x-rays and ultrasounds.  
 
You have been asked to pay a $20 copayment ($10 x 2 x-rays) for the diagnostic x-rays provided. 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 diagnostic mammography (77066) and the diagnostic digital 
breast tomosynthesis (G0279) provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a programming device evaluation provided 
on May 12, 2020. 
 
You asked the Plan to waive the copayment for a programming device evaluation. You say that you disagree 
with the charges because the doctor requested that you go into the office instead of a telehealth visit which 
would have not had a 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 $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for a programming device evaluation. A programming device 
evaluation 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 programming device evaluation provided on May 12, 
2020.