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

 
We decided that the Plan does not have to pay for medical services provided from June 7, 2017 to July 25, 
2017. 
 
You asked the Plan to pay for medical services. You say that the Plan should pay for these services because 
Medicare denied them. The Plan denied your request. The Plan says the Plan is not responsible for these 
services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The rules also state that Medicare plans are considered 
secondary insurers when an enrollee has another type of insurance. 
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record 
also shows that the enrollee was covered under liability insurance as of July 24, 2017, and this insurance is the 
primary payer. Therefore, we decided that the Plan does not have to pay for medical services provided from 
June 7, 2017 to July 25, 2017.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray services provided January 24, 
2020. 
 
You asked the Plan to waive the copayment for the x-ray services. You say that before the surgery the provider 
told you that the follow up visits would be covered 100% after surgery. You feel that these should all be 
included in the surgery cost as the provider promised. The Plan denied your request. The Plan says these claims 
processed with the correct copayment applied per the plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment for each Medicare covered standard x-ray service.  
 
You have been asked to pay $40 for the x-ray services. the x-ray 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 the x-ray services provided January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99292 x 2) provided November 15, 
2019. 
 
You asked the Plan to pay for two units of code 99292. You say that you would like reconsideration based on 
the medical records provided. The Plan denied your request. The Plan says two units of code 99292 is 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. 
 
In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes. 
 
We find that CPT code 99292 x 2 is not supported in the medical record. Specifically, the medical records do 
not document an additional 60 minutes of critical care time. Based on this information, we decided that 
Medicare rules for coverage of two units of code 99292 have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99292 x 2) provided November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic shoes and inserts you received 
on January 9, 2020. 
 
You asked the Plan to waive the coinsurance for the diabetic shoes and inserts. You say that when you ordered 
shoes before, you did not have coinsurance.  You also say that you shouldn't owe coinsurance on both the shoes 
and the inserts. The Plan denied your request. The Plan says you were charged this amount 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 therapeutic diabetic shoes and inserts.  
 
You have been asked to pay 20% coinsurance for the diabetic shoes and inserts. 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 diabetic shoes and inserts you received on January 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination (73562)  provided February 18, 2020. 
 
You asked the Plan to pay for the radiologic examination. You say that please find the attached x-ray 
documents supporting the procedure performed. The Plan denied your request. The Plan says the billed service 
cannot be verified. There is insufficient documentation to corroborate the services and confirm Medicare 
coverage has been met. 
 
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 73562 is radiologic examination, knee; 3 views. 
 
We find that CPT code 73562 is not supported in the medical record. Specifically, the records do not identify 
the number of views performed. Based on this information, we decided that Medicare rules for coverage of the 
radiologic examination have not been met. Therefore, we decided that the Plan does not have to pay for 
radiologic examination (73562)  provided February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on April 
13, 2020. 
 
You asked the Plan to pay for the provided items. The Plan denied your request. The Plan says the claim was 
billed more than the frequency allowance. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had a knee orthosis at the time the items at issue were received. The items at 
issue serve the same purpose as the orthosis previously provided to the enrollee. Addition codes will be denied 
as not reasonable and necessary if the base orthosis is not reasonable and necessary. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee orthosis and suspension sleeve provided on April 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B medication rendered on May 6, 
2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you have never received a bill that 
high. The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a Cost 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 for Medicare Part B covered chemotherapy drugs and other Part B covered drugs.  
 
Review of the file shows that you received Part B medication services on May 6, 2020. You have been asked to 
pay a 20% coinsurance for these services. These services fall within the for Medicare Part B covered 
chemotherapy drugs and other Part B covered drugs 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 Part B medication rendered on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for external electrocardiographic recording 
provided on February 25, 2020. 
 
You asked the Plan to waive the copayment for external electrocardiographic recording. You say that you were 
not informed of the cost ahead of time. 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 $170 
copayment for diagnostic procedure and tests provided in an outpatient hospital facility.  
 
You have been asked to pay the allowed amount of $131.05, which is less than the $170 copayment for 
external electrocardiographic recording. External electrocardiographic recording 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 external electrocardiographic recording provided on February 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for influenza virus vaccine provide on October 29, 2019. 
 
You asked the Plan to pay for the influenza virus vaccine. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for influenza virus vaccine provide on October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
2, 2020 and April 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the claims have been processed correctly 
per your plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 
copayment for ambulance.  
 
You have been asked to pay a $265 copayment for each of the ambulance services. The ambulance services fall 
within the ambulance services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services provided on April 2, 2020 and April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure, the 
fluoroscopy, and the injectable drugs you received in your doctor's office on February 24, 2020. 
 
You asked the Plan to waive the cost sharing for the medical services. You say that you had this same 
procedure in 2019 and paid less for it. The Plan denied your request. The Plan says you were charged this cost 
sharing appropriately. 
 
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 specialist services, a $100 copayment for radiological diagnostic services in a doctor?s office, 
and 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $40 copayment for the arthrocentesis procedure in your Evidence of Coverage.  
This service was performed in a specialist?s office, so this means that you have been asked to pay the correct 
amount based on your contract with the Plan. You have also been asked to pay a cost sharing for the 
fluoroscopy you had.  Your Evidence of Coverage says that you must pay a $100 copayment for radiological 
diagnostic services, such as a fluoroscopy, that you receive in your doctor?s office.  In this case, the total 
allowed amount for the fluoroscopy was $70.67.  Since the allowed amount is less than your copayment, you 
only have to pay $70.67 for this service.  Finally, you have been asked to pay 20% coinsurance for the three 
injectable Part B drugs you received.  The 20% coinsurance amount for these drugs is $1.80.  The total cost 
sharing for all of these services is $112.47 ($40 copayment + $70.67 copayment + 1.80 coinsurance.) 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 cost sharing for the arthrocentesis procedure, the fluoroscopy, and the 
injectable drugs you received in your doctor's office on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 25, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and 
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 $45 
copayment a specialist visit. 
 
You had a specialist visit on March 25, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the $45 copayment.   
 
You have been asked to pay a $45 copayment for a specialist visit. A 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 specialist visit provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided on February 4, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for assisted living services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider, facility or member. 
 
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 assisted living services provided on February 4, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on February 27, 2020. 
 
You asked the Plan to pay 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 service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on December 23, 2019. 
 
You asked the Plan to pay for the panoramic x-ray. You say that your insurance covers routine preventive 
dental care which includes exams, cleanings and x-rays. You say that you were not informed insurance 
wouldn't pay for it. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays, bitewing x-ray, unspecified endodontic 
procedure and therapeutic parenteral drug provided on March 26, 2020. 
 
You asked the Plan to pay for the intraoral x-rays, bitewing x-ray, unspecified endodontic procedure and 
therapeutic parenteral drug. You say that you were informed you had a copayment of $150. You say that you 
are requesting reimbursement because your coverage says you don't have a copayment. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-rays, bitewing x-ray, unspecified endodontic procedure and therapeutic parenteral drug provided on 
March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ziconotide injection services coded J2278 provided on 
January 7, 2020. 
 
You asked the Plan to pay for the ziconotide injection services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 J2278 is injection, ziconotide, 1 microgram. 
 
We find that CPT code J2278 is not supported in the medical record. Specifically, the documentation submitted 
does not support the 700 units billed for this service. Based on this information, we decided that Medicare rules 
for coverage of the ziconotide injection services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ziconotide injection services coded J2278 provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered outside of the United States on 
September 7, 2019 to September 22, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services 
furnished outside of the United States. The Plan contract says that you are covered for emergency are 
worldwide. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received services while out of the country. 
The Plan covers emergency care worldwide; however, the Plan rules state that the enrollee must pay for the 
services up front and submit a receipt or proof of payment for reimbursement. The Plan has not received this 
documentation from the enrollee to process the claim. Payment cannot be made until the Plan receives this 
information. Therefore, we decided that the Plan does not have to pay for the services rendered outside of the 
United States on September 7, 2019 to September 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 8, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 physician's services provided on October 8, 2019.