Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services received on December
12, 2019.
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered
benefit.
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. The rendering
provider has opted out of the Medicare program. The file shows that the rendering provider entered into a
private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the
office visit and related services received on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that early in the morning on the date of service, you were unable to speak, sit up, or swallow. You say that it is the first time it has ever happened and your spouse called 911. The responders arrived and after checking your blood sugar levels, they discovered it was low and gave you an IV. You say that you soon came around and were able to eat and drink something. You stated that the responders did not think it was necessary to transport you to the hospital but asked if you wanted to be transported and you declined. You say that you believe you should have a copay of some kind but should not be responsible for the entire bill. The Plan denied your request. The Plan says these services are not a covered benefit.
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 December 22, 2019. 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for chiropractic manipulative treatment (98940)
rendered by the out of network (OON) provider on February 17, 2020.
You asked the Plan to issue reimbursement 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 provided by an
out of network provider within the service area, 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. Additionally, coverage is provided for services rendered by an
out of network provider, out of the service area.
The service was rendered by an out of network provider, within the service area. The Plan has network
providers available who can provide the service at issue in this appeal. The Plan's Medical Director did not preapprove
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 issue reimbursement for chiropractic manipulative
treatment (98940) rendered by the out of network (OON) provider on February 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
December 24, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment because it should be covered by your 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 $50
copayment for emergency care.
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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
emergency room visit provided on December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis, RT (L1833) and suspension sleeve, RT
(L2397) provided November 7, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of
the service in dispute. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation
and management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis, RT
(L1833) and suspension sleeve, RT (L2397) provided November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of residual tooth roots (cutting procedure) (D7250)
and immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth)
(D5222) provided on February 5, 2020 by an in-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the
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. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for removal of residual
tooth roots (cutting procedure) (D7250) and immediate mandibular partial denture - resin base (including any
conventional clasps, rests and teeth) (D5222) provided on February 5, 2020 by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal x-ray provided on December 26, 2019.
You asked the Plan to pay for the x-ray services. You say that records support the procedure was performed by
the provider. The Plan denied your request. The Plan says the x-ray was previously approved and paid.
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 74018 is radiologic examination, abdomen; 1 view. We
find that CPT code 74018 is not supported in the medical record. The documentation shows that the x-ray at
issue was previously paid by the Plan. There is no documentation that shows the enrollee had a separate
procedure that requires separate billing. Based on this information, we decided that Medicare rules for coverage
have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray provided
on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on February 25,
2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient office visit. You say that you initially saw this provider for an eye
infection on February 18, 2020 and paid a $50 copay. You had a follow up with him on February 25, 2020 and
paid another $50 copay. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider. The plan says that non-emergent services with non-contracted providers
require prior-authorization prior to services being rendered.
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 outpatient office visit (99213) provided on
February 25, 2020 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 the remote evaluations provided on January
6, 2020.
You asked the Plan to waive the copayment for the remote evaluations. You say that you have never had to pay
this before. You say that you shouldn't be charged. The Plan denied your request. The Plan says the copayment
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 $35
copayment per visit to a specialist. Covered services include consultation, diagnosis, and treatment by a
specialist.
You have been asked to pay a $35 copayment for the remote evaluations. The remote evaluations fall 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 the remote evaluations provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), crown - porcelain fused to high noble metal (D2750) and core buildup, including any pins when required (D2950) provided on November 19, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. You exhausted your $1,500 annual maximum benefit allowance. Your EOC states, you have a $1,500 annual maximum (after the annual maximum is exhausted, any remaining charges are your responsibility.) Therefore, since you exhausted the $1,500 annual allowance you are responsible for the remainder of the cost. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), crown - porcelain fused to high noble metal (D2750) and core buildup, including any pins when required (D2950) provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on March 26, 2019.
You asked the Plan to pay for genetic tests. You say that you are appealing with medical records to support the
services billed. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because these tests are not a Medicare benefit for the diagnoses listed and were performed for screening
purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
genetic screening testing provided on March 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the abdomen & pelvis provided on December 11, 2019.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says 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 a CT scan of the abdomen & pelvis provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87801 and 87633 provided on February 11, 2020.
You asked the Plan to pay for the laboratory 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. We find that CPT codes 87801 and 87633 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81, however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87801 and 87633 provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from
December 30, 2019 to January 3, 2020.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were admitted to a
room on December 30, 2019 and were discharged on January 3, 2020. You say the copayment should be lower
for the 2020 dates of service. 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 $360
copayment for each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $360 copayment for 4 days of the inpatient hospital stay. ($360 x 4 = $1,440).
The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows your
inpatient hospital stay began in 2019 and the $360 copayment per day benefit applies to the entire inpatient
hospital stay.
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 reduce the copayment for the inpatient hospital stay provided from December 30,
2019 to January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 11, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that prior authorization should have been obtained
by the referring provider. The Plan denied your request. The Plan says no prior authorization was obtained.
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 physician services provided on December 11,
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on February 17, 2020.
You asked the Plan to pay for the dental services. You say that this was strictly for a diagnosis of a specific issue and it was not for a preventative service. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you had this service on January 13, 2020. Your EOC states, limited exam to evaluate a problem (D0140) - one (1) procedure per plan year. Therefore, we decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 23, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 23,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $300 for eyeglasses provided on June 12, 2019
You asked the Plan to reimburse you the eyeglasses. You say that you vision benefits were not made clear to
you when you called the Plan on June 5, 2019 and June 7, 2019. You say that there was a six month waiting list
for you to see the only local in-network vision provider, but you could not wait that long because your
dog chewed up your eyeglasses. The Plan denied your request. The Plan says you were reimbursed correctly
based on your routine vision benefits.
Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The requested provider in this case is not a network routine vision
provider with the Plan. The file shows you were reimbursed $100 per the maximum routine eyewear benefit.
Therefore, we decided that the Plan does not have to reimburse you $300 for eyeglasses provided on
June 12, 2019'
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine.
You asked the Plan to pre-approve Cyclobenzaprine. You say that the enrollee uses Cyclobenzaprine as needed
for her muscle cramps. You also say that this medication is medically necessary. The Plan denied your request.
The Plan says this drug is not covered for your condition by your Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine.
Benefits for Cyclobenzaprine may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.