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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 6, 2019. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this is being billed 
incorrectly. 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 $295 
copayment for outpatient surgery/in-network/outpatient hospital services.  
 
You have been asked to pay a $295 copayment for an outpatient surgery. The correct copayment has been 
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-
network/outpatient hospital 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 
an outpatient surgery provided by a participating provider on June 6, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for the EKG. 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to 
EKG's, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests. 
  
You have been asked to pay $19.55, which is less than the standard $30 copayment for the EKG. The EKG 
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 the EKG provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection services rendered on October 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 62323 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate CPT code.In this case, the CPT Code Manual definition of code 62323 is injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT).We find that CPT code 62323 is not supported in the medical record. Specifically, there is no documentation of a diagnostic or therapeutic injection with fluoroscopic guidance. 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 forthe injection services rendered on October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on June 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 specialist services provided on June 8, 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 specialist visits provided on July 29, 
2020 and August 26, 2020. 
 
You asked the Plan to waive the copayment for the specialist visits. You say that you weren't informed that 
virtual specialist appointments required a copayment. You say that you shouldn't be responsible for the 
payments. The Plan denied your request. The Plan says the copayments 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 $40 
copayment per visit to a specialist. Covered services include consultation, diagnosis, and treatment by a 
specialist.  
 
You have been asked to pay a $40 copayment for each specialist visit. The total amount you owe is $80 
($40/visit x 2 visits = $80). The specialist visits 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 
specialist visits provided on July 29, 2020 and August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the echocardiography, stress test, and 
myocardial perfusion imaging services you had on July 14, 2020. 
 
You asked the Plan to waive the cost sharing for the echocardiography, stress test, and myocardial perfusion 
imaging services. You say that if you had gone to the ER for care, your copayment would have been waived 
due to COVID-19. The Plan denied your request. The Plan says you were charged these cost sharing amounts 
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 $250 
copayment for advanced imaging services and 20% coinsurance for diagnostic tests in an outpatient hospital 
facility.  
 
You have been asked to pay a $250 copayment for myocardial perfusion imaging services and 20% 
coinsurance for the echocardiography and stress test. Myocardial perfusion imaging services fall within the 
advanced imaging services in an outpatient hospital facility benefit category. The echocardiography and stress 
test fall in the diagnostic procedures and tests category. This means that you have been asked to pay the correct 
amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. There is no provision in your contract for a waiver of these amounts. Therefore, 
we decided that the Plan does not have to waive the cost sharing for the echocardiography, stress test, and 
myocardial perfusion imaging services you had on July 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital on July 14, 2020.You asked the Plan to waive the copayment for a biopsy. Yousay that you were at an ambulatory surgical center and should only owe $275. 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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $350 copayment for a biopsy. When a facility is associated with a hospital, an outpatient hospital facility copayment is applied. A biopsy falls within the outpatient surgery/outpatient 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 an outpatient surgery provided by a participating hospital on July 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that the provider that you would 
like to see is 1 mile from your house. The Plan denied your request. The Plan says there are in-network 
providers available for these services. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services to be provided 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 chiropractic services (97012, 98941, 97110) provided on 
June 19, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you received a referral for services 
rendered. The Plan denied your request. The Plan says no referral was obtained. As a result, 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 chiropractic services (97012, 98941, 97110) 
provided on June 19, 2019, by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transport services provided to the enrollee on April 8, 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 due to the enrollee's hospice status at the time of service, this claim should be submitted 
to original Medicare. 
 
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 
transport services provided to the enrollee on April 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on June 
22, 2020. 
 
You asked the Plan to pay for this transport. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says paramedic intercept services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that billing provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided to the enrollee on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry technique for DNA or cell analysis 
(88189) provided on April 28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the flow cytometry technique for DNA or cell analysis. 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 flow cytometry technique for DNA or cell 
analysis (88189) provided on April 28, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forhospital observation services you received on August 8, 2020.You asked the Plan to waive the copayment forthe hospital observation services. You say that you would like this claim changed to inpatient.The Plan denied your request. The Plan says you were not admitted as an inpatient, you were kept in observation.  The Plan says that you were charged this copayment 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 $250 copayment for hospital observation services. You havebeen asked to pay a $250 copayment for the hospital observation services. Records show that you were clearly kept in observation while in the hospital and you were not admitted as an inpatient.  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 forhospital observation services you received on August 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve nursing visits. You say that the enrollee continues to require skilled nursing 
care for wound care. The Plan denied your request. The Plan says the enrollee has already been approved for 21 
skilled nursing visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve nursing visits. Our physician reviewer 
found that the enrollee has already been approved for 21 home health skilled nursing visits. The wound care 
being provided does not appear to be complex, and the wound does not appear to be infected. Additional 
nursing visits, beyond those already approved, are not shown to be medically necessary or reasonable. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nursing visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 24 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intravitreal injection provided on July 
2, 2020. 
 
You asked the Plan to waive the copayment for the intravitreal injection. You say that the doctor didn't do what 
he should have, and you had to get a second opinion. You say that the doctor should pay the copayment. 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 $275 
copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital 
outpatient facility.  
 
You have been asked to pay a $275 copayment for the intravitreal injection. The intravitreal injection 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 copayment for the intravitreal 
injection provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99204) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you are 
unhappy with your current provider and would like to see a new oncologist. The Plan denied your request. The 
Plan says they have redirected you to an additional in-network provider able to perform the requested medical 
services. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office or other outpatient visit (99204) to be provided 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 a CT scan of the head and brain (70450) 
performed on June 19, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the head and brain. You say that you should only 
be charged the emergency room copayment of $90. 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 $225 
copayment for each Medicare-covered advanced imaging service (not including X-rays).  
 
You have been asked to pay a $222.73 copayment for a CT scan of the head and brain. A CT scan of the head 
and brain falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
The Plan contract says that if advanced imaging services are received as part of an emergency department 
evaluation, then you will only pay the advanced imaging copayment, not the emergency room copayment. This 
means that you have been asked to pay less than or equal to 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 CT scan of the head and brain (70450) 
performed on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and bitewing x-
ray (D0270) provided on May 19, 2020 by an OON provider. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and bitewing x-ray. You say that it was 
difficult to find a dentist that was open during the lockdown. You also say that the office told you that they 
were on the books with your plan. The Plan denied your request. The Plan says the frequency limit for the 
bitewing x-ray has been exceeded. The Plan also says that the charge exceeds the allowable amount for the first 
intraoral periapical x-ray. 
 
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, bitewing x-rays are limited to one 
procedure per plan year. The record shows that you received bitewings (D0274) on January 10, 2020, and your 
bitewing x-rays benefit has been exhausted. The Plan also says that for services received OON, you are 
responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the 
Plan does not have to pay for the first intraoral periapical x-ray (D0220) and bitewing x-ray (D0270) provided 
on May 19, 2020 by an OON provider.