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

 
We decided that the Plan does not have to waive the copayment for the air ambulance services (A0431, A0436) 
received. 
 
You asked the Plan to waive the copayment for the air ambulance services. You say that you did not have a 
choice in how to be transported. The Plan denied your request. The Plan says you were charged this cost 
sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each air ambulance trip. You had 1 air ambulance trip. The Plan charged you $805.72, or 20% 
coinsurance of the Plan-allowed amount of $4,028.63, for these services. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the air ambulance services (A0431, A0436) received.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of skin and/or muscle (49002, 11043, 11046) 
provided on July 2, 2020, to July 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of skin and/or muscle. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the removal of skin and/or muscle (49002, 11043, 
11046) provided on July 2, 2020, to July 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for inpatient hospital services you received. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital services.. You say that you have 
received a demand letter from the hospital and want to know why this extra money is due. The Plan denied 
your request. The Plan says that you were appropriately charged your $1,000 annual deductible as well as a 
$750 copayment for the inpatient hospital services. 
 
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 $750 
copayment for inpatient hospital stays after your pay your $1,000 annual deductible.  
 
You have been asked to pay a total of $1750 for the services you received.  Specifically, you had not paid 
anything towards your $1,000 annual deductible prior to these services.  That is why you were assessed the full 
$1,000 deductible.  In addition, you have been asked to pay the applicable $750 copayment for the inpatient 
hospital admission in accordance with your Evidence of Coverage. 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 
cost sharing for inpatient hospital services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Monovisc injection you received from 
your orthopedist on January 6, 2020. 
 
You asked the Plan to waive the coinsurance for the Monovisc injection. You say that you should only have to 
pay the $35 specialist copayment, not this coinsurance. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 Medicare Part B drugs you received in a specialist's office.  
 
You have been asked to pay 20% coinsurance for the Monovisc injection. Your Evidence of Coverage states 
that you pay this coinsurance even if you get these services in a specialist's office. 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 Monovisc injection you received from your orthopedist on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and unspecified 
diagnostic procedure (D0999) provided on May 29, 2020. 
 
You asked the Plan to pay for dental codes D4910 and D0999. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the dental services received are 
not covered by Medicare or the Plan's supplemental dental 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, dental codes D4910 and D0999 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) and unspecified diagnostic procedure (D0999) provided on May 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on September 17, 2019. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this 
copayment. 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 $125 
copayment for transportation.  
 
You have been asked to pay a $125 copayment for an ambulance trip. An ambulance trip falls within the 
transportation 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 ambulance trip provided 
by a participating provider on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
requested provider is not a contracted provider and there are available contracted providers closer to the 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on March 10, 2020 and March 
11, 2020. 
 
You asked the Plan to pay for these services. You say that your dentist is charging you for the services. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services 
when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file shows that the Plan reimbursed the full $1,500 benefit 
maximum for these services. Further payment is not covered by Medicare or your supplemental dental benefit. 
Therefore, we decided that the Plan does not have to pay for the dental services rendered on March 10, 2020 
and March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiofrequency transmitter provided to the enrollee on 
March 9, 2020. 
 
You asked the Plan to pay for the transmitter. You say that this should be paid for. The Plan denied your 
request. The Plan says the documentation submitted did not include a valid physician order. 
 
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 L8683 is "Radiofrequency transmitter (external) for use 
with implantable neurostimulator radiofrequency receiver." 
 
We find that HCPCS code L8683 is not supported in the medical record. Specifically, there was no valid 
physician order to verify the denied code. Based on this information, we decided that Medicare rules for 
coverage of the transmitter have not been met. Therefore, we decided that the Plan does not have to pay for a 
radiofrequency transmitter provided to the enrollee on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
requested office visit services are not urgent or emergent and could be provided within the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays, comprehensive oral 
evaluation, and other preventive procedure provided on July 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the complete series of intraoral x-rays, comprehensive oral evaluation, and other 
preventive procedure. You say that you were treated by another provider that is in-network with the Plan. The 
Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan 
also says that no benefits are available for procedures performed by OON providers. 
 
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 
covered when they are received OON. The record shows that the Plan contacted the provider's office and 
confirmed that you received services from an OON provider. Therefore, we decided that the Plan does not have 
to pay for the complete series of intraoral x-rays, comprehensive oral evaluation, and other preventive 
procedure provided on July 6, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study (95811) provided May 30, 2020. 
 
You asked the Plan to pay for the sleep study. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there was no qualifying evaluation and management visit before the 
polysomnography. 
 
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 95811 is not supported in the medical record. Specifically, the documentation does not 
a qualifying Evaluation and Management visit within the past year prior to the sleep study being performed. 
For all diagnostic tests, including polysomnography, CMS requires an order from the provider who evaluates or 
treats the beneficiary. Based on this information, we decided that Medicare rules for coverage of the sleep 
study have not been met. Therefore, we decided that the Plan does not have to pay for a sleep study (95811) 
provided May 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient surgery you had on January 
24, 2020. 
 
You asked the Plan to waive the deductible for the outpatient surgery services. You say that the surgery was 
not successful so you shouldn?t have to pay for this. The Plan denied your request. The Plan says it has waived 
the $45 copayment originally charged for date of service February 6, 2020.  However, the Plan says that the 
deductible was assessed correctly for the outpatient surgery on January 24, 2020. 
 
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 after you pay your 
$1000 deductible, you pay a $350 copayment for outpatient surgery. 
 
Records show that you had outpatient surgery on January 24, 2020. At the time of the surgery, you had not yet 
paid anything towards your annual deductible.  According to your EOC, you have to pay a $1000 annual 
deductible before the Plan will pay for your care.  This deductible applies regardless of your satisfaction with 
the results of 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 deductible for the outpatient surgery you 
had on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 9, 
2019 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the enrollee's insurance company. You also say that the services were medically necessary, 
and provided in good faith. The Plan denied your request. The Plan says the services were rendered by an OON 
provider. The Plan also says that the enrollee was referred by her non-participating custodial care facility. 
 
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 subsequent nursing facility care provided on 
December 9, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 13, 2020 by an out of 
network (OON) 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 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 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 July 13, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special stain including interpretation and report (88313), 
level IV - surgical pathology, gross and microscopic examination (88305) and special stain including 
interpretation and report; group I for microorganisms (88312) provided by an out of network (OON) provider. 
 
You asked the Plan to pay for special stain including interpretation and report, level IV - surgical pathology, 
gross and microscopic examination and special stain including interpretation and report; group I for 
microorganisms. You say that you are an ancillary provider that patient cannot choose. The Plan denied your 
request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the special stain including interpretation and report 
(88313), level IV - surgical pathology, gross and microscopic examination (88305) and special stain including 
interpretation and report; group I for microorganisms (88312) provided by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for wound care. You say that you think you are being charged too 
much. 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 $225 
copayment for outpatient surgery/hospital facility.  
 
You have been asked to pay a $225 copayment for wound care. Wound care falls within the outpatient 
surgery/hospital facility 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 wound care 
provided by a participating provider.  
 
Please contact the Plan about payments you may have already made towards this copayment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical services you received on June 9, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you are 
disappointed with this charge.  You say that had you known this facility fee would apply, you would have gone 
to a different office. The Plan denied your request. The Plan says you were charged this copayment correctly.  
The Plan says that since the allowed amount for this service ($132.80) is less than your copayment, 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 $325 
copayment for Medicare-covered non-surgical visits in an outpatient clinic.  
 
You have been asked to pay the full amount for this service ($132.80 because it is less than the $325 
copayment for outpatient hospital services. Your Evidence of Coverage (EOC) clearly states that the outpatient 
hospital copayment may apply to services you receive at a hospital-affiliated clinic.  The EOC advises you to 
ask your provider if they charge the hospital fee for their services. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for medical services you received on June 9, 2020.