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

We decided that the Plan does not have to waive the copayment for an ultrasound behind the abdominal cavity
(76770) performed on January 28, 2020.
You asked the Plan to waive the copayment for an ultrasound behind the abdominal cavity. You say that a
representative of the Plan advised you that an ultrasound would have a $0 copayment. 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 $125
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.
You have been asked to pay a $30 copayment for an ultrasound behind the abdominal cavity. An ultrasound
behind the abdominal cavity falls within the Outpatient Diagnostic Tests and Therapeutic Services and
Supplies benefit category. You have been asked to pay a lower copayment for an ultrasound behind the
abdominal cavity than the full 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 behind the abdominal cavity (76770) performed on January 28, 2020.
Your complaint about inaccurate or misleading information provided to you by a representative of the Plan 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation (76377) provided on 
January 3, 2020. 
 
You asked the Plan to pay for the 3D rendering. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the 3D rendering. Our reviewer says that CPT code 76377 
does not meet criteria for billing or reimbursement consideration.` Our reviewer found the radiology report 
does not clearly indicate that a 3D rendering with interpretation and reporting was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 3D rendering have not been met. Therefore, we decided that the Plan does 
not have to pay for 3D rendering with interpretation (76377) provided on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 8, 
2020. 
 
You asked the Plan to pay for the services. You say that the enrollee coded and was pronounced dead before 
being loaded for transport. The Plan denied your request. The Plan says this is not a covered service, as the 
enrollee was not transported. 
 
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 February 8, 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 ambulance services provided to the enrollee on 
February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, tooth 9 (D3310) prefabricated post and 
core in addition to crown, tooth 9 (D2954) and porcelain crown, tooth 9 (D2750) provided on January 27, 2020 
to January 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you are requesting payment of service for your 
dental problems. You had no options as to consult your dental clinic for emergency help. You cannot afford to 
pay the amount. The Plan denied your request. The Plan says the enrollee did not have eligible dental coverage 
on the dates of service. Enrollee's must receive their services from an in-network provider. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for endodontic therapy, tooth 9 
(D3310) prefabricated post and core in addition to crown, tooth 9 (D2954) and porcelain crown, tooth 9 
(D2750) provided on January 27, 2020 to January 29, 2020 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 continuous glucose monitor supplies 
(K0553) provided January 24, 2020 to May 26, 2020. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor supplies. You say that there 
should be no copayment for the diabetic supplies. The Plan denied your request. The Plan says Continuous 
Glucose Monitors and supplies fall under the Durable Medical Equipment and Supplies category and therefore 
the correct coinsurance 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 continuous glucose monitor supplies. The continuous 
glucose monitor supplies fall 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 continuous glucose monitor supplies (K0553) provided January 24, 
2020 to May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee. 
 
You asked the Plan to pay for these services. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the imaging 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 imaging services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 to 
February 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says there is no 
authorization on file for the services in question. 
 
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 
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 February 14, 
2020 to February 21, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray exam of the lumbar spine (72114) 
provided on January 6, 2020. 
 
You asked the Plan to waive the copayment for this service. 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 service 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 $100 
copayment for basic radiological services provided in the outpatient department of a hospital.  
 
You have been asked to pay a $100 copayment for the radiology service 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 x-ray exam of the lumbar spine (72114) provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care from February 20, 2019 through 
March 6, 2019. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are appealing the hospitalization 
charges. The Plan denied your request. The Plan says this payment was recouped as the provider had been paid 
by the primary payer. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of inpatient hospital care have not been met. The primary payer paid 
more than the gross amount payable by Medicare for this hospital stay and therefore, no additional payment is 
due from the Plan. Therefore, we decided that the Plan does not have to pay for inpatient hospital care from 
February 20, 2019 through March 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on December 15, 2019. 
 
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 you by an out-of-network provider on 
December 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0428 and A0425) provided on December 25, 2019.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member was inpatient hospital status on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that this member was inpatient hospital status on the billed date of service. This means that these services are covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from the Prospective Payment System. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428 and A0425) provided on December 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services rendered on 
February 27, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you previously had the services 
covered with no copayment. 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 $20 
copayment per visit for urgently needed care.  
 
You have been asked to pay a $20 copayment per visit for these services. these services falls within the 
urgently needed 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 the urgent care 
services rendered on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 14, 
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 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 physician services provided to the enrollee on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
March 14, 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 Medicare does not pay separately for this service. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this code is a column II to 
the more comprehensive column I codes 36556 and 77001. An appropriate modifier was not appended 
indicating that the service was distinct. 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 radiology 
services (CPT 71045) provided to the enrollee on March 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on March 10, 
2020. 
 
You asked the Plan to waive the copayment for the spinal injection. You say that you were never made aware 
that you would have a copayment for this service. You say this is an injection that should be covered by 
insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each out-of-network outpatient hospital visit.  
 
You have been asked to pay a $250 copayment for the spinal injection. The spinal injection falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers? benefit category. The record shows that the spinal injection is considered a surgical procedure. 
 
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 spinal injection provided on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the humerus (73060) provided on January 23, 
2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were not emergent or pre-authorized. There were network providers 
available. 
 
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 an x-ray of the humerus (73060) provided on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on January 7, 2020.
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you were not aware that this provider was not in the Plan's network. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 50% coinsurance for out-of-network outpatient surgery at an outpatient hospital. The allowed amount of this claim is $7,785.23, resulting in a coinsurance obligation of $3,892.61. You have been asked to pay 50% coinsurance for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including 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 coinsurance for outpatient surgery provided on January 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for ambulance transport provided on April 28, 2020.
You asked the Plan to waive this copayment. You say that you could not walk and an ambulance was necessary. The Plan denied your request. The Plan says the Plan covered the transport however, the copayment is your cost share for the service per your 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 $350 copayment for ambulance transport. 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 $350 copayment charged for ambulance transport provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip injection provided on February 11, 
2020. 
 
You asked the Plan to waive the copayment for the hip injection. You say that you made the appointment for an 
office visit. You say you do not agree with the outrageous amount charged for using their facility. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. For this date of 
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 
copayment for the hip injection. 
 
You have been asked to pay a $261.80 copayment for the hip injection. The hip injection 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 the hip injection provided on February 11, 
2020.